All Insurance Policy Changes (Page 121)

Continuing from page 120. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

Medium impact
Ocular Surface Disease Diagnosis and Treatments - Medicare Advantage (Revised)
Humana·Effective Jul 1, 2026
This Medicare Advantage policy (effective 07/01/2026) establishes updated coverage criteria for ocular surface disease (OSD) diagnosis and treatment procedures. The policy requires specific diagnostic testing (ocular surface staining, Schirmer test, tear osmolarity, etc.) and documented failure of conventional medical management before covering advanced treatments like amniotic membrane transplantation, punctal plugs, tarsorrhaphy, and surgical eyelid corrections.
Medium impact
Nuclear Imaging for Noncancer Indications - Medicare Advantage (Revised)
Humana·Effective Jul 1, 2026
Humana Medicare Advantage revised its Nuclear Imaging for Noncancer Indications policy effective July 1, 2026, establishing updated medical necessity criteria for FDG PET, PET/CT, and Beta Amyloid PET imaging. For jurisdictions without local coverage determinations, the policy now references LCD L39521 criteria for inflammation/infection cases, and establishes specific diagnostic requirements for Alzheimer's disease amyloid imaging including provider experience, blood work, imaging, and documentation that results will influence treatment.
Medium impact
Niktimvo™ (axatilimab-csfr) (New)
Humana·Effective Jul 1, 2026
Humana Indiana Medicaid has established a new prior authorization policy for Niktimvo™ (axatilimab-csfr), a specialized IV infusion therapy for chronic Graft vs Host Disease (cGVHD). Billing teams must now obtain prior authorization before dispensing this drug, requiring verification that patients meet three specific clinical criteria: confirmed cGVHD diagnosis, failure of at least two prior systemic therapies, and minimum weight of 40 kg. This policy is effective immediately and applies to all Niktimvo intravenous solution administration under Indiana Medicaid.
Medium impact
Niktimvo™ (axatilimab-csfr) (New)
Humana·Effective Jul 1, 2026
Humana Medicaid (Ohio) has established a new prior authorization policy for Niktimvo™ (axatilimab-csfr), effective July 1, 2026. This intravenous medication for chronic Graft vs Host Disease (cGVHD) requires prior authorization and must meet three specific criteria: documented cGVHD diagnosis, failure of at least two prior systemic therapy lines, and patient weight of at least 40 kg. The billing team must implement prior authorization workflows before claims are submitted.
High impact
Minimal Residual Disease Testing - Medicare Advantage (Revised)
Humana·Effective Jul 1, 2026
Humana Medicare Advantage revised its Minimal Residual Disease (MRD) testing policy effective 07/01/2026, establishing coverage criteria for MRD tests in both hematologic malignancies (e.g., ClonoSEQ) and solid tumors (e.g., Guardant360 Response, Signatera). The policy requires alignment with applicable CMS Local Coverage Determinations (LCDs) by Medicare Administrative Contractor jurisdiction and establishes medical necessity criteria based on analytical validity, clinical validity, and clinical utility. Billing teams must verify jurisdiction-specific LCD requirements and ensure proper prior authorization and documentation before claims submission.
Low impact
Mepsevii™ (vestronidase alfa-vjbk) (New)
Humana·Effective Jul 1, 2026
Humana Medicaid (Ohio) has established a new prior authorization requirement for Mepsevii (vestronidase alfa-vjbk), a rare enzyme replacement therapy for Mucopolysaccharidosis VII (MPS VII/Sly syndrome). This is a new pharmacy coverage policy effective July 1, 2026, requiring prior authorization for all Mepsevii intravenous infusions in pediatric and adult patients with confirmed MPS VII diagnosis. The policy includes a black box warning for anaphylaxis risk, requiring healthcare professional supervision during infusion.
Medium impact
Mental Health Day Treatment - MEDICAID - OHIO (New)
Humana·Effective Jul 1, 2026
Humana Healthy Horizons Ohio has established a new Medicaid prior authorization policy for Mental Health Day Treatment services, effective 07/01/2026. The policy requires providers to submit authorization requests at least 7 days in advance (standard) or 2 days for expedited requests using ODM-approved forms, and requires medical necessity documentation. Services rendered with KX crisis modifier are excluded from prior authorization requirements.
Medium impact
Lymphedema - Diagnosis and Treatment - Medicare Advantage (Revised)
Humana·Effective Jul 1, 2026
This is a Medicare Advantage policy revision (effective 07/01/2026) that establishes coverage criteria for lymphedema diagnosis and treatment services, including bioimpedance spectroscopy (BIS), compression garments, manual lymph drainage, and pneumatic compression devices. The policy specifies medical necessity requirements, frequency limits, and eligible patient populations for Humana Medicare Advantage plans.
Medium impact
Loargys® (pegzilarginase-nbln) injection solution (New)
Humana·Effective Jul 1, 2026
Humana Medicaid (Ohio) has established a new prior authorization policy for Loargys® (pegzilarginase-nbln) injection solution, effective July 1, 2026. Coverage requires provider attestation of Arginase 1 Deficiency diagnosis, member age ≥2 years, and concurrent protein-restricted diet. All claims for this medication must obtain prior authorization before dispensing.
Medium impact
Loargys® (pegzilarginase-nbln) injection solution (New)
Humana·Effective Jul 1, 2026
Humana Medicaid (Louisiana) has established a new prior authorization policy for Loargys® (pegzilarginase-nbln) injection solution effective July 1, 2026, for treating Arginase 1 Deficiency in patients 2 years and older. Prior authorization requires provider attestation of ARG1-D diagnosis, confirmation of patient age ≥2 years, and documentation that the member will use the drug with a protein-restricted diet. All claims for this medication must obtain prior authorization before dispensing to avoid denial.
Low impact
Blue Cross and Blue Shield of Illinois Recommended Once Again for State’s Medicaid Managed Care Program
BCBS Illinois·Effective Jan 1, 2027
Blue Cross and Blue Shield of Illinois (BCBSIL) has been reselected as one of six Managed Care Organizations for Illinois' HealthChoice Medicaid program. New member enrollment begins later in 2026 with coverage starting January 1, 2027. BCBSIL will continue serving approximately 700,000 Medicaid members under the Blue Cross Community Health Plans.
High impact
Attention Provider Type 22 (Dental): Expanded Coverage for Adults 21 Years and Older
Nevada Medicaid·Effective Jul 1, 2026
Effective July 1, 2026, Nevada Medicaid (Provider Type 22 - Dental) is expanding adult dental coverage for members 21+ to include diagnostic, preventative, periodontal, and operative services (fillings and crowns). All newly covered services are subject to a $1,000 per calendar year expenditure limit, with new error code 5751 applying to claims exceeding this threshold. Emergency and palliative care remain unlimited.
High impact
Attention Provider Type (PT) 17 Specialty 181 (Federally Qualified Health Centers (FQHC)): Implementation of Dental Shadow Billing, January 1, 2027
Nevada Medicaid·Effective Jan 1, 2027
Nevada Medicaid is implementing Dental Shadow Billing for FQHCs effective January 1, 2027. FQHCs providing dental services must transition from CPT 41899 (CMS 1500 form) to ADA code D2999 (ADA form/837D transactions), discontinue DBA Supplemental Payment billing after December 31, 2026, and configure systems to use Primary and Supplementary Shadow Billing Codes for dental encounter reporting.
Low impact
July 1, 2026 Kaiser Permanente opens its first northern Nevada medical offices Locations will provide primary, laboratory, pharmacy, and imaging health …
Kaiser Permanente·Effective Jul 1, 2026
Kaiser Permanente is opening its first northern Nevada medical offices on July 1, 2026, offering primary care, laboratory, pharmacy, and imaging services. This is a service expansion announcement rather than a policy change affecting billing codes, coverage, or reimbursement.
High impact
Cardiac Event Detection
Medicare/CMS - LCD·Identified Jul 2, 2026
⚠️ CRITICAL: This policy (L34573 - Cardiac Event Detection) is RETIRED as of 6/27/2026 and is no longer in effect. The billing team must immediately cease using this policy for any coverage determinations. This policy should NOT be referenced for new claims or appeals. Verify current cardiac event detection coverage requirements with your current LCD or contact Palmetto GBA for the replacement policy.
Medium impact
Cardiac Event Detection
Medicare/CMS - LCD·Identified Jul 2, 2026
Failed to analyze policy change
Medium impact
We’ve Reviewed Prior Authorization Exemptions for May 1, 2025, Through April 30, 2026
BCBS Texas·Effective Jul 1, 2026
Blue Cross Blue Shield of Texas has completed its annual review of prior authorization exemptions effective May 1, 2025 through April 30, 2026, with results now available as of July 1, 2026. Providers who qualified for exemptions must submit notifications through Availity Essentials to determine initial length of stay or units exempted, and must understand that services beyond initial exemption limits remain subject to medical necessity review and concurrent review requirements.
Medium impact
MMP 26-19: Additions to Standards of Coverage and Documentation Requirements for High Frequency Chest Wall Oscillation (HFCWO) Devices
Michigan Medicaid - MDHHS·Effective Aug 1, 2026
Michigan Medicaid is adding new coverage standards and documentation requirements for High Frequency Chest Wall Oscillation (HFCWO) devices effective August 1, 2026. All initial HFCWO devices must now include an equipment usage meter, and DME providers must document the device serial number, delivery date, and meter readings (start/end) at delivery and at four-month intervals. Continuation of therapy requires ongoing meter documentation showing prescribed treatment compliance.
High impact
MMP 26-24: Hospital 15-Day Readmissions
Michigan Medicaid - MDHHS·Effective Aug 1, 2026
Effective August 1, 2026, Michigan Medicaid changes hospital readmission reimbursement policy. Readmissions within 15 days to a DIFFERENT hospital for the same condition now receive full separate payment (instead of bundled payment). Readmissions to the same hospital for related conditions remain bundled as a single episode. Unrelated readmissions are always paid separately regardless of hospital.
Medium impact
MMP 26-25: Revision to Home Help Comprehensive Assessment Policy
Michigan Medicaid - MDHHS·Effective Aug 1, 2026
Michigan Medicaid is replacing in-person home comprehensive assessments with phone interviews for Home Help clients transferring to new counties, but only when the client changes providers or household composition changes affecting IADL proration. Home Help payments cannot be authorized until the phone interview is completed. This streamlines the assessment process while maintaining eligibility controls.
Medium impact
MMP 26-26: Revisions to MI Coordinated Health Program Policy
Michigan Medicaid - MDHHS·Effective Aug 1, 2026
MMP 26-26 revises Michigan's MI Coordinated Health (MICH) program policy effective August 1, 2026, clarifying requirements for HIDE SNPs operating in four defined regions. Key changes include updated Individualized Care Plan (ICP) requirements for HCBS waiver enrollees, removal of the Personal Care Services Reasonable Time Schedule (RTS), clarification on concurrent enrollment with behavioral health programs, new rules for Adaptive Medical Equipment coverage, out-of-state disenrollment procedures, and mandatory provider enrollment in CHAMPS with criminal history reviews.
Medium impact
Enhance Behavioral Health Outcomes
Florida Blue·Effective Jul 1, 2026
Florida Blue is implementing enhanced performance tracking on five HEDIS behavioral health quality measures (IET, FUM, FUH, FUI, FUA) effective July 2026. Providers must ensure timely follow-up care within 7-30 days after ED visits or hospitalizations for mental illness and substance use disorders, and coordinate care through available resources including Lucet Behavioral Health Network and case management services. This is a quality/outcomes tracking initiative rather than a billing code or coverage change, but non-compliance with follow-up requirements may impact quality scores and future reimbursement.
High impact
[Ohio] OAC 5160-13-08, Add-On Payment for Nursing Facility-Based Hemodialysis Furnished by a Dialysis Center
CareSource·Effective Jul 1, 2026
Ohio Medicaid (CareSource) is implementing a new $110 per-treatment add-on payment for nursing facility-based hemodialysis services furnished by dialysis centers, effective July 1, 2026. Dialysis centers must bill using a designated HD revenue center code with an ODM-specified modifier to claim this add-on. The program is subject to a $2.1 million state budget cap and applies only during State Fiscal Year 2027 for dialysis centers already providing these services.
High impact
Upcoming Policies effective September 7, 2026
Blue Cross and Blue Shield of Minnesota·Effective Sep 7, 2026
Blue Cross Minnesota has revised spinal cord stimulation (SCS) and dorsal root ganglion (DRG) stimulation coverage policy effective September 7, 2026, establishing stricter medical necessity criteria for trial and permanent implants, including mandatory 6-month conservative management, psychological evaluation, and 6-week smoking cessation requirements. A new policy classifies implantable knee shock absorbers as experimental/investigative. The policy on Psychological and Neuropsychological Testing (X-45) has been inactivated.
Medium impact
Developmental Disabilities Individual Budgeting (iBudget) Waiver
Florida Medicaid·Effective Jul 1, 2026
Florida Medicaid is amending the iBudget Waiver (effective July 1, 2026) to expand eligibility by adding Tatton-Brown-Rahman Syndrome (TBRS) as a covered developmental disability diagnosis, updating the definition of 'developmental disability,' and clarifying background screening requirements for providers. A 30-day public comment period runs through July 30, 2026.

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Archive by year

2023 2024 2025 2026

Ocular Surface Disease Diagnosis and Treatments - Medicare Advantage (Revised)

Nuclear Imaging for Noncancer Indications - Medicare Advantage (Revised)

Niktimvo™ (axatilimab-csfr) (New)

Niktimvo™ (axatilimab-csfr) (New)

Minimal Residual Disease Testing - Medicare Advantage (Revised)

Mepsevii™ (vestronidase alfa-vjbk) (New)

Mental Health Day Treatment - MEDICAID - OHIO (New)

Lymphedema - Diagnosis and Treatment - Medicare Advantage (Revised)

Loargys® (pegzilarginase-nbln) injection solution (New)

Loargys® (pegzilarginase-nbln) injection solution (New)

Blue Cross and Blue Shield of Illinois Recommended Once Again for State’s Medicaid Managed Care Program

Attention Provider Type 22 (Dental): Expanded Coverage for Adults 21 Years and Older

Attention Provider Type (PT) 17 Specialty 181 (Federally Qualified Health Centers (FQHC)): Implementation of Dental Shadow Billing, January 1, 2027

July 1, 2026 Kaiser Permanente opens its first northern Nevada medical offices Locations will provide primary, laboratory, pharmacy, and imaging health …

Cardiac Event Detection

Cardiac Event Detection

We’ve Reviewed Prior Authorization Exemptions for May 1, 2025, Through April 30, 2026

MMP 26-19: Additions to Standards of Coverage and Documentation Requirements for High Frequency Chest Wall Oscillation (HFCWO) Devices

MMP 26-24: Hospital 15-Day Readmissions

MMP 26-25: Revision to Home Help Comprehensive Assessment Policy

MMP 26-26: Revisions to MI Coordinated Health Program Policy

Enhance Behavioral Health Outcomes

[Ohio] OAC 5160-13-08, Add-On Payment for Nursing Facility-Based Hemodialysis Furnished by a Dialysis Center

Upcoming Policies effective September 7, 2026

Developmental Disabilities Individual Budgeting (iBudget) Waiver