All Insurance Policy Changes (Page 39)

Continuing from page 38. 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
Upcoming Self-Measured Blood Pressure (SMBP) Monitoring Webinar
Missouri Medicaid (MO HealthNet)·Effective Feb 1, 2025
MO HealthNet is hosting an educational webinar on August 26, 2026, to inform prescribers and DME providers about Self-Measured Blood Pressure (SMBP) Monitoring coverage that became effective February 1, 2025. SMBP-validated monitoring devices are now covered when prescribed by physicians or authorized healthcare professionals to participating DME providers, with prescriptions requiring appropriately sized cuff requests.
High impact
Changes to Preferred Biosimilar Medications Effective October 1, 2026
Missouri Medicaid (MO HealthNet)·Effective Oct 1, 2026
MO HealthNet is changing preferred biosimilar medications effective October 1, 2026. Infliximab, Adalimumab, and Ustekinumab will have new preferred and non-preferred agent designations. Patients currently on non-preferred agents must switch to preferred versions unless an override is approved. Existing prior authorizations remain valid, but mandatory product switching will be enforced at the fiscal edit level.
Medium impact
Provider Updates for August 2026
Healthfirst·Effective Aug 1, 2026
Healthfirst updated its Allergen Testing policy (PO-RE-059v6) effective August 1, 2026, establishing specific coverage criteria for in-vitro IgE testing, total serum IgE testing, and exclusions for non-covered tests like ALCAT, basophil activation testing, and bead-based epitope assays. Billing teams must ensure claims are submitted only for covered scenarios: allergen-specific IgE testing (up to 20 allergens/year based on clinical history), total IgE for moderate-to-severe asthma or ABPA symptoms, and annual re-testing for food allergen resolution in pediatric patients. Claims for routine re-testing, same-day testing with skin prick tests, and excluded methodologies will be denied.
Medium impact
World Lung Cancer Day (Aug 1): Documentation and Coding Resources for Your Practice
Healthfirst·Effective Aug 1, 2024
Healthfirst has released updated documentation and coding guidance for lung cancer cases to ensure accurate ICD-10-CM code selection and proper clinical documentation. The policy provides specific coding rules for primary malignancies, secondary/metastatic disease, carcinoma in situ, screening encounters, and post-treatment surveillance, along with required documentation elements including neoplasm type, diagnostic tests, treatment modality, and risk factors.
Medium impact
Point32Health medical drug program updates
Harvard Pilgrim Health Care·Effective Aug 1, 2026
Point32Health updated prior authorization requirements and coverage criteria for 7 medical benefit drugs across multiple plans, effective August 1 and October 1, 2026. Key changes include: Vyjuvek now covers all ages (not age-restricted), Zolgensma requires documentation of no prior gene therapy, Epioxa no longer requires prior auth for keratoconus, Imaavy has updated PA criteria, Vykoura added to step therapy, Starjemza becomes preferred ustekinumab product, and Adstiladrin PA management moved to OncoHealth.
Medium impact
Lemtrada® (alemtuzumab) (New)
Humana·Effective Dec 1, 2025
Humana Medicaid Ohio has implemented a new prior authorization policy for Lemtrada (alemtuzumab), a monoclonal antibody for relapsing forms of multiple sclerosis. This is a brand-new policy effective December 1, 2025, requiring prior authorization before dispensing. The drug carries significant safety warnings including black box warnings for autoimmunity, infusion reactions, stroke, and malignancies, and should only be used after inadequate response to two or more MS disease-modifying therapies.
High impact
Skin and Tissue Substitutes - MEDICAID - INDIANA (New)
Humana·Effective May 20, 2026
Humana Indiana Medicaid has established a new coverage policy for skin and tissue substitutes (effective 05/20/2026) that limits coverage to two specific indications: diabetic foot ulcers and chronic venous leg ulcers, both requiring 4+ weeks duration and strict compliance with standard wound care requirements. All other indications are now considered not medically necessary. Billing teams must immediately identify and update claims submission workflows to align with these coverage restrictions and ensure proper prior authorization documentation.
Medium impact
Fractional Flow Reserve with Computed Tomography - MEDICAID - OKLAHOMA (Revised)
Humana·Effective Jul 29, 2026
Humana Medicaid Oklahoma has established a NEW coverage policy for Fractional Flow Reserve with Computed Tomography (FFRCT), effective 07/29/2026. This is a brand new policy (not a revision) that defines specific medical necessity criteria for CPT 75580, including required CCTA-confirmed stenosis ranges (40-90%), risk stratification, and explicit exclusion criteria. Billing teams must implement prior authorization requirements and ensure provider documentation meets the defined clinical criteria.
Medium impact
Rystiggo (rozanolixizumab-noli) (New)
Humana·Effective Aug 1, 2026
Humana Medicaid (Ohio) has established a new prior authorization policy for Rystiggo (rozanolixizumab-noli), effective August 1, 2026. This monoclonal antibody is approved for generalized myasthenia gravis (gMG) in anti-AChR or anti-MuSK antibody-positive patients who have failed or are intolerant to pyridostigmine and at least one immunosuppressive therapy. Prior authorization is required before dispensing, with approval valid for the plan year.
Medium impact
Rystiggo (rozanolixizumab-noli) (New)
Humana·Effective Aug 1, 2026
Humana Medicaid Indiana has established a new prior authorization policy for Rystiggo (rozanolixizumab-noli), effective August 1, 2026. This monoclonal antibody is covered for generalized myasthenia gravis (gMG) patients who are anti-AChR or anti-MuSK antibody positive and have failed or cannot tolerate pyridostigmine and at least one immunosuppressive therapy. All prescriptions require prior authorization, confirmation of antibody status, specialist oversight, and documented prior treatment attempts.
High impact
Remodulin® (treprostinil) (New)
Humana·Effective Aug 1, 2026
Humana Indiana Medicaid has established a new prior authorization policy for Remodulin® (treprostinil) effective August 1, 2026. The policy requires prior authorization for pharmacy claims and specifies five clinical criteria that must be met for coverage approval, including confirmed PAH diagnosis via right heart catheterization, WHO Functional Class II-IV status, failed/ruled-out oral calcium channel blockers, disease progression despite maximal therapy, and significant symptoms. This is a NEW policy (1 day old) requiring immediate implementation.
Medium impact
Pluvicto (lutetium Lu 177 vipivotide tetraxetan) (New)
Humana·Effective Aug 1, 2026
Humana Indiana Medicaid is establishing a new prior authorization requirement for Pluvicto (lutetium Lu 177 vipivotide tetraxetan), a radioligand therapeutic for PSMA-positive metastatic castration-resistant prostate cancer (mCRPC). Effective August 1, 2026, all Pluvicto claims require prior authorization and must meet specific clinical criteria including PSMA-positive disease confirmation, prior ARPI therapy failure, and appropriate candidate status relative to taxane-based chemotherapy. Maximum benefit is limited to 6 doses at intervals of at least 6 weeks per plan year.
Medium impact
Pluvicto (lutetium Lu 177 vipivotide tetraxetan) (New)
Humana·Effective Aug 1, 2026
Humana Medicaid (Louisiana) is establishing a new prior authorization policy for Pluvicto (lutetium Lu 177 vipivotide tetraxetan), a radioligand therapeutic for PSMA-positive metastatic castration-resistant prostate cancer. Effective August 1, 2026, all Pluvicto claims require prior authorization verification of four clinical criteria plus documented PSMA-positive disease confirmation and ARPI therapy failure, with maximum coverage of 6 doses.
Medium impact
Korsuva™ (difelikefalin) (New)
Humana·Effective Aug 1, 2026
Humana Indiana Medicaid has established a new prior authorization policy for Korsuva (difelikefalin), an IV medication for treating chronic kidney disease-associated pruritus in hemodialysis patients. The policy requires prior authorization for initial approval (6 months) and renewal requests, with specific clinical criteria that must be met. Billing teams must implement prior auth requirements immediately for this new drug coverage effective August 1, 2026.
Medium impact
Imaavy intravenous solution (nipocalimab-aahu) (New)
Humana·Effective Aug 1, 2026
Humana Medicaid (Ohio) has issued a new prior authorization policy effective August 1, 2026 for Imaavy (nipocalimab-aahu), a monoclonal antibody for treating generalized myasthenia gravis (gMG). Billing teams must implement prior authorization requirements for this newly covered medication for anti-AChR or anti-MuSK antibody-positive gMG patients who have failed or cannot tolerate pyridostigmine and at least one immunosuppressive therapy. All claims for Imaavy require prior authorization approval before dispensing to avoid claim denials.
Medium impact
Imaavy intravenous solution (nipocalimab-aahu) (New)
Humana·Effective Aug 1, 2026
Humana Medicaid (Indiana) has established a new prior authorization policy for Imaavy (nipocalimab-aahu), a monoclonal antibody for treating generalized myasthenia gravis (gMG) in anti-AChR or anti-MuSK antibody positive patients. Coverage requires confirmation of gMG diagnosis with specific antibody testing and documented trial or contraindication of pyridostigmine plus at least one immunosuppressive therapy. This is a brand-new coverage pathway effective August 1, 2026.
High impact
Shoulder Arthroplasty - Medicare Advantage (Revised)
Humana·Effective Aug 3, 2026
Humana Medicare Advantage has updated its shoulder arthroplasty coverage policy (HUM-1207-008), effective 08/03/2026. The policy establishes medical necessity criteria for total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (rTSA), hemi-arthroplasty, and revision procedures, with specific documentation and conservative treatment requirements that billing teams must verify before claim submission.
Medium impact
Pharmacogenomics Testing - Medicare Advantage (Revised)
Humana·Effective Aug 3, 2026
Humana Medicare Advantage has updated its Pharmacogenomics Testing policy (effective 08/03/2026) to clarify coverage requirements across multiple MAC jurisdictions. The policy establishes that pharmacogenomics testing is covered only when ordered by a treating physician, meets clinical validity standards, and demonstrates clinical utility for specific medical problems—not for screening or risk assessment. Billing teams must verify MAC-specific LCD/LCA requirements by geographic jurisdiction before processing claims.
Medium impact
Peripheral Nerve Stimulators - Medicare Advantage (Revised)
Humana·Identified Aug 4, 2026
Humana Medicare Advantage has released a revised policy on Peripheral Nerve Stimulators covering devices used to treat pain, nausea, vomiting, and essential tremors. The policy distinguishes between transcutaneous electrical nerve stimulation (TENS) and other stimulation methods, with devices that may be skin-based or implanted. The provided content is incomplete, preventing full assessment of coverage criteria, billing implications, and any prior authorization requirements.
High impact
Percutaneous Coronary Intervention - Medicare Advantage (Revised)
Humana·Effective Aug 3, 2026
Humana Medicare Advantage updated its Percutaneous Coronary Intervention (PCI) coverage policy effective August 3, 2026, clarifying medical necessity criteria for PCI procedures and adding specific coverage requirements for Coronary Intravascular Lithotripsy (IVL) when treating severely calcified coronary stenosis. The policy applies MAC-specific LCDs across multiple jurisdictions and establishes that PCI is covered for acute coronary syndrome, chest pain despite optimal medical therapy, in-stent restenosis, recent STEMI, and silent ischemia.
Medium impact
Penile Prosthesis Implant for Erectile Dysfunction - Medicare Advantage (Revised)
Humana·Effective Aug 3, 2026
This is a revised Medicare Advantage policy (effective 08/03/2026) clarifying coverage criteria for penile prosthesis implants for erectile dysfunction. The policy establishes specific medical necessity requirements including comprehensive history/exam, documented failure of conservative management, and 6-month persistence of ED. Additionally, the policy explicitly excludes coverage for vacuum erection devices, stem cell therapy, and shockwave therapy (LI-ESWT) due to insufficient evidence.
Medium impact
Orthotics - Medicare Advantage (Revised)
Humana·Effective Aug 3, 2026
Humana has revised its Medicare Advantage Orthotics policy (HUM-1177-006), effective August 3, 2026. This policy establishes coverage requirements and guidelines for orthotic devices including braces, splints, casts, and advanced technologies (exoskeletons, microprocessor-controlled devices, myoelectric orthotics). The policy references specific CMS Local Coverage Determinations and requires providers to follow Medicare's 'reasonable and necessary' standard for all orthotic claims.
High impact
Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)
Humana·Effective Aug 6, 2026
This is a comprehensive Medicare Advantage coverage policy for neuroablative techniques used to treat chronic pain, effective 08/06/2026. The policy defines coverage criteria, eligible procedures (including radiofrequency ablation, cryoablation, chemical neurolysis, and specialized devices like Intracept), and references MAC-specific LCDs and billing codes by geographic jurisdiction. Billing teams must verify applicable MAC guidelines for their state and ensure claims comply with local coverage determinations.
High impact
Negative Pressure Wound Therapy - Medicare Advantage (Revised)
Humana·Effective Aug 3, 2026
This is a revised Medicare Advantage policy for Negative Pressure Wound Therapy (NPWT) effective August 3, 2026. The policy clarifies coverage determination based on CMS Local Coverage Determinations (LCDs) that vary by MAC jurisdiction, with Humana using LCD L35125 (Wound Care) criteria for medical necessity determination on NPWT services (CPT 97605-97608). Billing teams must ensure claims comply with jurisdiction-specific LCD requirements and document medical necessity per the specified wound care criteria.
Medium impact
Liquid Biopsy - Medicare Advantage (Revised)
Humana·Effective Aug 3, 2026
Humana Medicare Advantage has updated its Liquid Biopsy coverage policy (Policy HUM-1151-014), effective 08/03/2026. This policy establishes coverage criteria for liquid biopsy tests (blood-based biomarker analysis for cancer detection and treatment monitoring) across multiple jurisdictions under Medicare Administrative Contractors. The policy requires medical necessity documentation and adherence to MAC-specific Local Coverage Determinations, with coverage determined through analytical/clinical validity standards and DEX Registry evaluation where CMS guidance is absent.

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Archive by year

2023 2024 2025 2026

Upcoming Self-Measured Blood Pressure (SMBP) Monitoring Webinar

Changes to Preferred Biosimilar Medications Effective October 1, 2026

Provider Updates for August 2026

World Lung Cancer Day (Aug 1): Documentation and Coding Resources for Your Practice

Point32Health medical drug program updates

Lemtrada® (alemtuzumab) (New)

Skin and Tissue Substitutes - MEDICAID - INDIANA (New)

Fractional Flow Reserve with Computed Tomography - MEDICAID - OKLAHOMA (Revised)

Rystiggo (rozanolixizumab-noli) (New)

Rystiggo (rozanolixizumab-noli) (New)

Remodulin® (treprostinil) (New)

Pluvicto (lutetium Lu 177 vipivotide tetraxetan) (New)

Pluvicto (lutetium Lu 177 vipivotide tetraxetan) (New)

Korsuva™ (difelikefalin) (New)

Imaavy intravenous solution (nipocalimab-aahu) (New)

Imaavy intravenous solution (nipocalimab-aahu) (New)

Shoulder Arthroplasty - Medicare Advantage (Revised)

Pharmacogenomics Testing - Medicare Advantage (Revised)

Peripheral Nerve Stimulators - Medicare Advantage (Revised)

Percutaneous Coronary Intervention - Medicare Advantage (Revised)

Penile Prosthesis Implant for Erectile Dysfunction - Medicare Advantage (Revised)

Orthotics - Medicare Advantage (Revised)

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Negative Pressure Wound Therapy - Medicare Advantage (Revised)

Liquid Biopsy - Medicare Advantage (Revised)