All Insurance Policy Changes (Page 74)

Continuing from page 73. 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
Sutent (sunitinib) (Revised)
Humana·Effective Jan 1, 2026
Humana revised its Sutent (sunitinib) prior authorization policy effective January 1, 2026, with updates finalized July 22, 2026. This pharmacy coverage policy establishes specific clinical criteria and exclusions for sunitinib approval across seven cancer indications (RCC adjuvant, thymomas/thymic carcinoma, GIST, advanced RCC, PNET, advanced thyroid carcinoma, and angiosarcoma). Key requirement: brand Sutent requests mandate documented intolerance or contraindication to generic sunitinib, and members with prior disease progression on sunitinib are excluded from coverage.
High impact
Simponi (golimumab) (Revised)
Humana·Effective Jan 1, 2026
Humana has revised its Simponi (golimumab) pharmacy coverage policy for Medicare Advantage members, effective January 1, 2026, with a July 22, 2026 revision. The policy establishes prior authorization requirements for Simponi across four indications (Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis, and Ulcerative Colitis) with updated criteria requiring prior failure/contraindication/intolerance to specific biologic therapies before approval.
Medium impact
Rinvoq (upadacitinib) LQ Oral Solution (Revised)
Humana·Effective Jan 1, 2026
Humana has issued a revised prior authorization policy for Rinvoq (upadacitinib) LQ Oral Solution effective January 1, 2026, with updates as of July 22, 2026. Coverage is limited to two indications: psoriatic arthritis and polyarticular juvenile idiopathic arthritis in patients age 2+ with prior TNF blocker failure, contraindication, or intolerance. Prior authorization is required for all Rinvoq LQ oral solution prescriptions under this policy.
High impact
Rinvoq (upadacitinib) Extended Release Tablet (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage updated its Rinvoq (upadacitinib) prior authorization policy, effective January 1, 2026, with a revision date of July 22, 2026. The policy establishes specific clinical criteria for coverage across 9 indications including rheumatoid arthritis, psoriatic arthritis, atopic dermatitis, ulcerative colitis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, Crohn's disease, polyarticular juvenile idiopathic arthritis, and giant cell arteritis. All claims for Rinvoq must meet diagnosis, age, and prior therapy requirements before authorization.
Low impact
Wound Care - MEDICAID - LOUISIANA (Revised)
Humana·Effective Jul 20, 2026
This is a routine annual review of Louisiana Medicaid's wound care policy with NO coverage changes. The policy reaffirms that wound care supplies require prior authorization (3-month periods with documented medical necessity), wound care systems (thermal or sealed suction) are covered for specific indications (Stage III/IV chronic wounds, post-surgical dehiscence, non-adhering grafts), and portable hyperbaric oxygen chambers remain non-covered. Billing teams should ensure they continue applying these existing requirements without workflow modifications.
Medium impact
Yulithira (everolimus) (New)
Humana·Effective Jul 22, 2026
Humana has implemented a new prior authorization policy for Yulithira (everolimus) effective July 22, 2026, covering five oncologic and non-oncologic indications. All requests require documentation of intolerance or contraindication to generic everolimus AND meeting specific clinical criteria. Members with prior disease progression on everolimus are excluded from coverage across all indications.
Medium impact
Uterine Fibroid Surgical Treatments - MEDICAID - KENTUCKY (Revised)
Humana·Effective Jul 22, 2026
Humana Kentucky Medicaid will NOT cover cryoablation procedures for uterine fibroids (CPT 58578, 58999), effective 07/22/2026. The policy states there is insufficient medical evidence to support this as standard treatment. Prior authorization is required, but will be denied. This represents a non-coverage determination for a specific surgical intervention.
Medium impact
Thiopurine S-Methyltransferase Enzyme Activity Testing - MEDICAID - VIRGINIA (New)
Humana·Effective Jul 22, 2026
Humana Medicaid Virginia establishes new coverage for TPMT enzyme activity testing (CPT 84433) effective 07/22/2026. The test is covered for two indications: guiding thiopurine medication dosing prior to therapy initiation, or evaluating severe toxicity from thiopurine drugs. Members under 21 require medical necessity review per EPSDT requirements. This is a new policy with no prior guidance superseded.
Medium impact
Thiopurine S-Methyltransferase Enzyme Activity Testing - MEDICAID - INDIANA (New)
Humana·Effective Jul 22, 2026
Humana Indiana Medicaid now covers TPMT enzyme activity testing (CPT 84433) for two specific indications: to guide medication dosing before initiating thiopurine therapy (azathioprine, mercaptopurine, thioguanine) or to assess severe toxicity from existing thiopurine therapy. This is a new policy effective July 22, 2026, with special EPSDT review requirements for members under age 21.
High impact
Spinal Fusion and Stabilization Surgery - MEDICAID - OHIO (New)
Humana·Effective Jul 22, 2026
Humana Healthy Horizons Ohio Medicaid has established a new clinical coverage policy for spinal fusion and stabilization surgery effective July 22, 2026. The policy outlines medical necessity criteria, prior authorization requirements, and coverage guidelines for procedures including artificial intervertebral disc replacement, corpectomy, facet joint replacement, and sacroiliac joint fusion. Billing teams must verify prior authorization requirements through the Ohio Medicaid Prior Authorization and Notification List and ensure all supporting documentation is submitted with authorization requests.
High impact
Spinal Decompression Surgery - MEDICAID - VIRGINIA (New)
Humana·Effective Jul 22, 2026
Humana Medicaid Virginia has released a new comprehensive spinal decompression surgery policy (effective 07/22/2026) establishing specific coverage criteria for discectomy, laminectomy, foraminectomy, and related procedures. The policy requires documented medical necessity including diagnostic imaging confirmation, failed conservative treatment (6 weeks minimum), and specific clinical/neurological findings. Billing teams must verify all authorization requirements before submitting claims for these procedures.
High impact
Spinal Decompression Surgery - MEDICAID - SOUTH CAROLINA (Revised)
Humana·Effective Jul 22, 2026
Humana revised its South Carolina Medicaid spinal decompression surgery coverage policy effective July 22, 2026, establishing specific medical necessity criteria for discectomy, laminectomy, foraminectomy, and related procedures. The policy defines coverage requirements based on diagnosis (herniated disc, myelopathy, fractures, infections, tumors), requires documented conservative treatment failure (6 weeks minimum), and specifies clinical and objective findings needed for approval. Billing teams must ensure prior authorization requests include diagnostic imaging confirmation and evidence of conservative treatment attempts before surgery.
High impact
Spinal Decompression Surgery - MEDICAID - MICHIGAN (New)
Humana·Effective Jul 22, 2026
Humana Medicaid Michigan has released a new spinal decompression surgery coverage policy (effective 07/22/2026) that establishes specific clinical criteria for coverage of discectomy, laminectomy, foraminectomy, and related procedures. The policy requires documented medical necessity including imaging confirmation, failed conservative treatment (typically 6 weeks), and specific clinical/neurological findings. Billing teams must verify these criteria are met before submitting claims to avoid denials.
High impact
Spinal Decompression Surgery - MEDICAID - INDIANA (New)
Humana·Effective Jul 22, 2026
Humana Indiana Medicaid released new coverage criteria for spinal decompression surgery effective 07/22/2026. This policy establishes specific medical necessity requirements for discectomy, laminectomy, foraminectomy, and related procedures, including diagnostic imaging confirmation and conservative treatment trials (6 weeks minimum for radicular pain). Billing teams must verify patient eligibility against these criteria before submitting claims to avoid denials.
High impact
Skin and Tissue Substitutes - MEDICAID - OHIO (Revised)
Humana·Effective Jul 22, 2026
Humana Healthy Horizons Ohio Medicaid establishes medical necessity criteria for coverage of skin and tissue substitutes (bioengineered cellular and acellular matrices) for treatment of diabetic foot ulcers and chronic venous leg ulcers lasting >4 weeks. The policy requires prior authorization and mandates comprehensive documentation including offloading, infection management, glycemic control, and wound care standards. Providers must submit authorization requests with medical necessity documentation before services are rendered to avoid claim denials and financial penalties.
Medium impact
Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) (New)
Humana·Effective Jul 22, 2026
Humana Medicaid Ohio has established a new prior authorization policy for Rylaze (asparaginase erwinia chrysanthemi recombinant-rywn), effective July 22, 2026. Coverage requires ALL diagnosis of ALL/LBL, documented Grade 2-4 hypersensitivity to prior pegaspargase therapy, and use as part of multi-agent chemotherapy. Four serious exclusions apply: history of serious pancreatitis, thrombosis, hemorrhagic events, or disease progression on asparaginase therapy.
High impact
Spinal Decompression Surgery - MEDICAID - OKLAHOMA (New)
Humana·Effective Jul 29, 2026
Humana Oklahoma Medicaid establishes new coverage criteria for spinal decompression surgery (laminectomy, laminotomy, foraminectomy, foraminotomy) in cervical and lumbar spine. Policy requires specific clinical documentation, imaging correlation, and 6-week conservative treatment failure for most diagnoses, with exceptions for emergent conditions (fractures, infections, tumors, cauda equina syndrome). Billing teams must ensure prior authorization submissions include required medical necessity documentation.
High impact
Presumptive Eligibility for Supplemental Security Income Recipients
Nevada Medicaid·Effective Jul 22, 2026
Nevada Medicaid has changed Presumptive Eligibility (PE) rules effective immediately: individuals who are deemed eligible for or currently receiving Supplemental Security Income (SSI) can no longer be evaluated under any PE category (Hospital or Pregnancy). These applicants must be denied PE and referred to the Division of Social Services for regular Medicaid application instead.
High impact
Medicaid Services Manual Chapters Updated
Nevada Medicaid·Effective Jul 1, 2026
Nevada Medicaid updated four service manual chapters effective July 1-6, 2026. Key changes include: (1) Pharmacy Lock-In reduced from 108 to 24 months with new good cause criteria; (2) Multiple new drug clinical criteria added (Aqvesme, Itvisma, Exdensur, Tryvio, Pivya, and ATTR agents); (3) Prior authorization submission process streamlined to allow direct QIO vendor submission for Personal Care Services and Intermediary Service Organizations; (4) Youth peer support services maximum age increased to 26 years. These changes affect prior authorization workflows, pharmacy benefits management, and service eligibility determinations.
High impact
Attention All Providers: Updated Forms Available
Nevada Medicaid·Effective Jul 22, 2026
Nevada Medicaid has updated 50+ prior authorization and request forms with cosmetic changes to reflect the transition to Nevada Medicaid branding. No content changes were made to the forms themselves. Providers must immediately begin using the 07/13/2026 dated versions; forms submitted on older versions will be rejected starting August 13, 2026.
High impact
Attention Provider Type 63 (Psychiatric Residential Treatment Facility (PRTF)): Rate Reform Implemented for Private PRTFs
Nevada Medicaid·Effective Jan 1, 2025
Nevada Medicaid implemented rate reform for private Psychiatric Residential Treatment Facilities (PRTF, Provider Type 63) effective January 1, 2025. Private PRTFs now receive a flat rate of $800 for revenue codes 100 and 183, with an optional $150 add-on (maximum $950) for children under 10 or those with complex needs. Prior authorization using new revenue code 120 and form FA-15 is required for the add-on rate, effective August 1, 2026. Retroactive claim reprocessing has begun for eligible claims.
High impact
2026.38 - Provider Bulletin - Policy Updates and Changes to Clinical Review Criteria
Connecticut Medicaid (HUSKY Health)·Effective Aug 1, 2026
Connecticut CMAP (HUSKY Health) is implementing significant clinical review criteria changes effective August 1, 2026. Five new policies are being introduced (BPH treatment, prostate cancer focal treatment, baroreflex device, corneal crosslinking, and corneal surgical procedures), 23 existing policies are being updated, and 4 policies are being retired. Billing teams must obtain updated clinical criteria from the HUSKY Health portal and implement new prior authorization requirements.
Medium impact
DSS Important Message - Updates to Skin Substitutes Listed on the Physician Office and Outpatient Fee Schedule
Connecticut Medicaid (HUSKY Health)·Effective Jul 1, 2026
Effective July 1, 2026, prior authorization is no longer required for select skin substitutes on the physician office and outpatient fee schedule. Billing teams must review the updated fee schedule to identify which skin substitute codes no longer require prior authorization and update their workflows accordingly.
Low impact
DSS Important Message - Multi-Factor Authentication (MFA) Security Updates Effective July 14, 2026
Connecticut Medicaid (HUSKY Health)·Effective Jul 14, 2026
The Connecticut Medical Assistance Program (CMAP) Secure Web Portal is implementing MFA security updates effective July 14, 2026. Users will be limited to one enrolled Authenticator App device per account (multiple devices must be removed), and users enrolled in both Authenticator App and Email Verification methods can choose their preferred authentication method at login.
Medium impact
DSS Important Message - Open Office Hours for Multi-Factor Authentication /Security Questions; Multi-Factor Authentication Mandated Enrollment on August 1, 2026; Security Question Updates, Notifications
Connecticut Medicaid (HUSKY Health)·Effective Aug 1, 2026
Connecticut Medical Assistance Program (CMAP) is mandating Multi-Factor Authentication (MFA) enrollment for all providers, trading partners, and drug labelers accessing the secure web portal by August 1, 2026. MFA was optional since June 2, 2026, but becomes mandatory on the deadline. Users must choose between authenticator app or email verification methods. Additionally, security questions have been restructured to use dropdown menus (effective May 13, 2026) rather than free-form entries.

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Archive by year

2023 2024 2025 2026

Sutent (sunitinib) (Revised)

Simponi (golimumab) (Revised)

Rinvoq (upadacitinib) LQ Oral Solution (Revised)

Rinvoq (upadacitinib) Extended Release Tablet (Revised)

Wound Care - MEDICAID - LOUISIANA (Revised)

Yulithira (everolimus) (New)

Uterine Fibroid Surgical Treatments - MEDICAID - KENTUCKY (Revised)

Thiopurine S-Methyltransferase Enzyme Activity Testing - MEDICAID - VIRGINIA (New)

Thiopurine S-Methyltransferase Enzyme Activity Testing - MEDICAID - INDIANA (New)

Spinal Fusion and Stabilization Surgery - MEDICAID - OHIO (New)

Spinal Decompression Surgery - MEDICAID - VIRGINIA (New)

Spinal Decompression Surgery - MEDICAID - SOUTH CAROLINA (Revised)

Spinal Decompression Surgery - MEDICAID - MICHIGAN (New)

Spinal Decompression Surgery - MEDICAID - INDIANA (New)

Skin and Tissue Substitutes - MEDICAID - OHIO (Revised)

Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) (New)

Spinal Decompression Surgery - MEDICAID - OKLAHOMA (New)

Presumptive Eligibility for Supplemental Security Income Recipients

Medicaid Services Manual Chapters Updated

Attention All Providers: Updated Forms Available

Attention Provider Type 63 (Psychiatric Residential Treatment Facility (PRTF)): Rate Reform Implemented for Private PRTFs

2026.38 - Provider Bulletin - Policy Updates and Changes to Clinical Review Criteria

DSS Important Message - Updates to Skin Substitutes Listed on the Physician Office and Outpatient Fee Schedule

DSS Important Message - Multi-Factor Authentication (MFA) Security Updates Effective July 14, 2026

DSS Important Message - Open Office Hours for Multi-Factor Authentication /Security Questions; Multi-Factor Authentication Mandated Enrollment on August 1, 2026; Security Question Updates, Notifications