MedicaidPrior AuthHigh impact
25-173m Medical Policies - January 2025
Health Net·CA · Oncology, PM&R (Physical Medicine & Rehab), Pain Management +4 more·Prior Authorization
Effective date
Jan 1, 2025
We identified it
Jun 20, 2026
Summary
CalViva Health updated multiple prior authorization policies for January 2025, including expanded criteria for proton beam therapies, updated DME codes, revised biofeedback requirements, and modified criteria for hyperhidrosis treatments and other specialized procedures. These changes affect coverage criteria and billing codes across multiple medical specialties.
Action Required
Immediately: Update prior authorization workflows for all affected policies including proton beam therapy (expanded criteria for multiple cancer types and age limit changed to ≤21), DME equipment (new codes E0678, E0679, L2006, E2298), and biofeedback treatments (removed session limits). Review coverage criteria for hyperhidrosis treatments, urinary incontinence devices, pain pumps, and sleep apnea devices. Update billing system with new HCPCS codes and ensure staff verify prior authorization requirements before scheduling affected procedures.