MedicaidPrior AuthMedium impact
25-1359m Updates to Clinical Policies - November 2025
Health Net·CA · Transplant Surgery, Wound Care, Pediatrics +4 more·Prior Authorization
Effective date
Nov 1, 2025
We identified it
Jun 20, 2026
Summary
CalViva Health updated multiple clinical policies for November 2025, including changes to prior authorization requirements for electric tumor treating fields, sleep studies, mechanical stretching devices, pediatric oral function therapy, skin/tissue substitutes, and transplant documentation. Key changes include new coverage criteria, expanded code coverage, and updated documentation requirements.
Action Required
By November 1, 2025: Billing team must update prior authorization requirements for affected policies. Add new HCPCS codes E1820, E1828, E1829, E1830, E1832 to mechanical stretching device coverage criteria. Remove Q4104 and Q4106 from non-covered skin substitute codes list. Update skin substitute billing to reflect new 4-application initial limit with potential extension to 8 applications. Verify CalViva Health members meet updated criteria before submitting claims.