All Insurance Policy Changes (Page 76)

Continuing from page 75. 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
11.15.24a, Migraine Deactivation Surgery
Independence Blue Cross·Identified Jul 23, 2026
Failed to analyze policy change
Medium impact
07.03.26b, Tumor Treating Fields
Independence Blue Cross·Identified Jul 23, 2026
Failed to analyze policy change
Medium impact
11.00.06w, Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring
Independence Blue Cross·Effective Jul 22, 2026
Policy 11.00.06w regarding Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring has been reissued for commercial plans, effective 07/22/2026. The billing team must obtain and review the full policy details to identify specific changes to coverage criteria, billing codes, prior authorization requirements, or documentation standards that may affect claim submission and reimbursement for sleep apnea treatments.
Medium impact
07.03.01d, Home-Based Sleep Studies
Independence Blue Cross·Effective Jul 22, 2026
Unable to provide complete analysis. The policy document referenced (07.03.01d, Home-Based Sleep Studies) was not included in the source material. Only metadata was provided showing this is a commercial policy reissued on 07/22/2026. The actual policy content, specific billing codes, coverage changes, and detailed requirements are needed to generate actionable guidance for the billing team.
Medium impact
05.00.56l, Hospital Beds and Accessories
Independence Blue Cross·Effective Jul 22, 2026
Policy 05.00.56l regarding Hospital Beds and Accessories has been reissued effective 07/22/2026. Without access to the full policy text content, the specific changes cannot be determined. The billing team must review the complete policy document to identify what coverage, coding, or documentation requirements have changed for hospital bed and accessory claims.
Medium impact
08.01.87a, Sutimlimab-jome (Enjaymo)
Independence Blue Cross·Identified Jul 23, 2026
Failed to analyze policy change
Medium impact
08.01.49b, Burosumab-twza (Crysvita®)
Independence Blue Cross·Identified Jul 23, 2026
Failed to analyze policy change
Medium impact
09.00.42d, Computer-Aided Detection (CAD) System for Use with Chest Radiographs
Independence Blue Cross·Effective Jul 22, 2026
Policy 09.00.42d regarding Computer-Aided Detection (CAD) System for Use with Chest Radiographs has been reissued effective 07/22/2026. The full policy content was not provided in the source material, so specific coverage changes, billing code impacts, or authorization requirements cannot be determined from this notice alone. Billing team must obtain the complete policy document to identify specific billing codes, coverage determinations, and any workflow changes.
High impact
Guidance for Medicare/Medi-Cal Crossover Claim Submission on the Paper CMS-1500
Medi-Cal·Effective Jul 21, 2026
California Medi-Cal has issued updated guidance for submitting Medicare/Medi-Cal crossover claims on paper CMS-1500 forms. Providers must now submit crossover claims directly to the California MMIS Fiscal Intermediary at a specific Sacramento address, with strict formatting requirements for key CMS-1500 fields (Boxes 1, 1A, 9A, and 11C) and must attach a corresponding Medicare Remittance Notice with each submission. Claims not meeting these requirements will be returned.
Medium impact
Drug Policy Criteria Change
Arkansas Blue Cross Blue Shield·Identified Jul 22, 2026
Failed to analyze policy change
High impact
[Ohio] Post-Acute Prior Authorization Request Worksheet
Anthem BCBS·Effective Jul 21, 2026
Anthem Blue Cross Blue Shield (Ohio) has updated its Post-Acute Prior Authorization Request Worksheet for Medicare Advantage plans. Providers must now use the updated worksheet when submitting clinical information for SNF, inpatient rehab, and LTACH admission requests and continued stay reviews. Failure to use the worksheet or submit required clinical documentation may result in authorization delays, claim denials, and delays in member transitions to appropriate care levels.
High impact
[Georgia] Telehealth claims update: ICD-10-CM Excludes1 editing
Anthem BCBS·Effective Sep 1, 2026
Effective September 1, 2026, Anthem Blue Cross Blue Shield (Georgia) will apply ICD-10-CM Excludes1 editing rules to telehealth claims billed with Place of Service 02 or 10, matching standards applied to other claim types. Claims with diagnosis code combinations prohibited by Excludes1 notes may be denied for reimbursement. Providers must verify diagnosis codes do not violate Excludes1 conventions before submission.
High impact
Rate Update for DHSS-Authorized Home and Community-Based Services
Missouri Medicaid (MO HealthNet)·Effective Jul 21, 2026
This policy updates reimbursement rates for DHSS-authorized home and community-based services effective July 21, 2026. The billing team must verify the specific rate changes in the full policy document and update fee schedules, billing software, and claim submission processes to reflect new payment amounts to ensure accurate reimbursement and avoid underbilling.
Low impact
Optimizing Benefits for Maternal and Infant Health Meetings
Missouri Medicaid (MO HealthNet)·Identified Jul 22, 2026
This is a provider education and networking event announcement from MO HealthNet Division regarding maternal and infant health benefits. No billing policy changes, coverage modifications, or procedural updates are included—this is purely informational about in-person meetings scheduled across Missouri from September 2026 through January 2027.
Medium impact
Elaprase® (idursulfase) (Revised)
Humana·Effective Jul 22, 2026
This is a revised Humana prior authorization policy for Elaprase® (idursulfase) for Hunter Syndrome treatment, effective July 22, 2026. The policy requires prior authorization and confirms that coverage applies to Medicare and Medicaid (Kentucky and South Carolina) members with a confirmed diagnosis of Hunter Syndrome (Mucopolysaccharidosis II). The single approval criterion is diagnosis verification; specific dosing (0.5 mg/kg IV weekly) and administration requirements are outlined but approval duration details are incomplete in the provided document.
Medium impact
Egrifta® (tesamorelin acetate) (Revised)
Humana·Effective Jul 22, 2026
Humana revised its Egrifta (tesamorelin acetate) pharmacy coverage policy for Medicare Advantage members with HIV-associated lipodystrophy. The policy maintains prior authorization requirements and reinforces three clinical eligibility criteria: confirmed HIV-associated lipodystrophy diagnosis, use of Egrifta for abdominal fat reduction, and prior/current use of protease inhibitors (PI) and/or nucleoside reverse transcriptase inhibitors (NRTI). The revision updates monitoring requirements for IGF-1 levels, glucose status, and retinopathy.
Medium impact
Lumizyme® (alglucosidase alpha) (Revised)
Humana·Effective Jan 1, 2011
This is a revised Humana prior authorization policy for Lumizyme (alglucosidase alpha) for treatment of Pompe disease, effective for Medicare and Medicaid (Kentucky and South Carolina) members. The policy requires prior authorization and establishes that members must have a confirmed diagnosis of Pompe disease to receive coverage. The revision date of July 22, 2026 indicates this is a current policy update that supersedes any previous guidance.
Low impact
Chenodal™ (chenodiol) (Revised)
Humana·Effective Jan 1, 2015
This is a revised Medicare Advantage prior authorization policy for Chenodal (chenodiol) tablets used to treat radiolucent gallstones. The policy was updated on July 22, 2026, and requires prior authorization before dispensing. Coverage is limited to patients with radiolucent gallstones in well-opacifying gallbladders who are not surgical candidates and have failed or cannot tolerate ursodiol therapy. Patients with pre-existing liver disease are excluded.
Medium impact
Pancreatic Enzymes (Revised)
Humana·Effective Jul 22, 2026
This is a revised Humana Medicare Advantage pharmacy policy for pancreatic enzymes (Pancreaze, Pertzye, Viokace) effective immediately as of the revision date July 22, 2026. The policy implements a step therapy requirement: members must have previous treatment with or documented intolerance to both Creon AND Zenpep before approval for the covered pancreatic enzyme products. This is a step therapy policy requiring prior authorization before dispensing.
Medium impact
Clinical Trials Policy (Revised)
Humana·Effective Jul 22, 2026
Humana revised its Clinical Trials Pharmacy Policy effective July 22, 2026, clarifying coverage criteria for routine care and services costs associated with FDA-approved and federally-funded clinical trials for cancer and life-threatening illnesses. The policy specifies what IS covered (medically necessary complications, conventional care items) and what IS NOT covered (investigational drugs themselves, data collection costs, sponsor-provided items, and non-standard services). For Medicaid members under 21 in Healthy Horizons plans, off-label/non-compendium treatments in clinical trials may be reconsidered under EPSDT criteria when no standard treatment exists.
Medium impact
Myalept® (metreleptin) (Revised)
Humana·Effective Jan 1, 2017
Humana updated its Myalept (metreleptin) prior authorization policy for Medicare Advantage members, effective January 1, 2017, with a recent revision dated July 22, 2026. The policy requires prior authorization for Myalept subcutaneous solution when treating congenital or acquired generalized lipodystrophy, with strict exclusions for partial lipodystrophy, liver disease (including NASH), HIV-related lipodystrophy, and generalized obesity. The policy emphasizes REMS program requirements, boxed warnings regarding anti-metreleptin antibodies and lymphoma risk, and approval duration determined by plan year or clinical review.
Low impact
Cycloset® (bromocriptine) (Revised)
Humana·Effective Jan 1, 2017
This is a revised Medicare Advantage pharmacy policy for Cycloset® (bromocriptine) that clarifies step therapy approval criteria. Members automatically qualify for Cycloset coverage if they have prior treatment experience with, contraindication to, or intolerance of metformin-containing medications. The policy maintains plan-year approval durations for both initial and renewal requests.
Medium impact
Aliqopa™ (copanlisib) (Revised)
Humana·Effective Jul 22, 2026
Humana Medicare Advantage revised its Aliqopa (copanlisib) prior authorization policy effective July 22, 2026. The policy maintains coverage for relapsed/refractory follicular lymphoma patients who have received at least two prior systemic therapies and are using Aliqopa as monotherapy, with approval granted for 6-month durations. Key exclusion: patients with prior PI3K inhibitor disease progression are not eligible.
Medium impact
Oncaspar® (pegaspargase) (Revised)
Humana·Effective Jul 22, 2026
Humana revised its Oncaspar (pegaspargase) prior authorization policy effective July 22, 2026. The policy maintains prior authorization requirements for ALL members with acute lymphoblastic leukemia (ALL) using Oncaspar as part of multi-agent chemotherapy, with five key exclusions that will trigger approval denial (disease progression on prior Oncaspar, serious thrombosis/pancreatitis/hemorrhage with prior asparaginase, or total bilirubin >10x ULN). Approval duration remains 6 months for both initial and renewal.
Medium impact
Palynziq™ (pegvaliase-pqpz) Injection (Revised)
Humana·Effective Jul 22, 2026
This is a revised Palynziq (pegvaliase-pqpz) pharmacy coverage policy for Humana Medicaid plans in Kentucky and South Carolina, effective July 22, 2026. The policy establishes prior authorization requirements for this pegylated enzyme replacement therapy used to treat phenylketonuria (PKU) in adult patients with uncontrolled phenylalanine levels >600 micromol/L. Billing teams must ensure prior authorization is obtained before dispensing and verify members meet all three clinical criteria.

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2023 2024 2025 2026

Insurance Policy Changes Tracker: All Payer Updates (Page 76) | PolicyChanges.app

11.15.24a, Migraine Deactivation Surgery

07.03.26b, Tumor Treating Fields

11.00.06w, Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring

07.03.01d, Home-Based Sleep Studies

05.00.56l, Hospital Beds and Accessories

08.01.87a, Sutimlimab-jome (Enjaymo)

08.01.49b, Burosumab-twza (Crysvita®)

09.00.42d, Computer-Aided Detection (CAD) System for Use with Chest Radiographs

Guidance for Medicare/Medi-Cal Crossover Claim Submission on the Paper CMS-1500

Drug Policy Criteria Change

[Ohio] Post-Acute Prior Authorization Request Worksheet

[Georgia] Telehealth claims update: ICD-10-CM Excludes1 editing

Rate Update for DHSS-Authorized Home and Community-Based Services

Optimizing Benefits for Maternal and Infant Health Meetings

Elaprase® (idursulfase) (Revised)

Egrifta® (tesamorelin acetate) (Revised)

Lumizyme® (alglucosidase alpha) (Revised)

Chenodal™ (chenodiol) (Revised)

Pancreatic Enzymes (Revised)

Clinical Trials Policy (Revised)

Myalept® (metreleptin) (Revised)

Cycloset® (bromocriptine) (Revised)

Aliqopa™ (copanlisib) (Revised)

Oncaspar® (pegaspargase) (Revised)

Palynziq™ (pegvaliase-pqpz) Injection (Revised)