Medicare AdvantagePrior AuthHigh impact
Medical and Clinical Policy Updates - Winter 2026
Sentara Health Plans·Oncology, Radiology, General Surgery +2 more·Medical Policy
Effective date
Feb 1, 2026
We identified it
Feb 25, 2026
Summary
Sentara Health Plans released Winter 2026 medical policy updates affecting multiple service lines with staggered effective dates (February 1 and April 1, 2026). Key changes include archiving Medical 34 (Genetic and Molecular Testing) with routing to OncoHealth or Avalon authorization systems, revising policies for prescription digital therapeutics, orthotics/braces, lumbar laminectomy, and adopting Evolent 2026 Advanced Imaging Guidelines. Billing teams must implement new authorization workflows and update system configurations before effective dates.
Action Required
REQUIREMENTS:
By January 31, 2026: Billing and authorization teams must:
1. Stop processing Medical 34 (Genetic and Molecular Testing) through standard MCG authorization after February 1, 2026
2. Configure system routing for genetic testing requests: oncology cases to OncoHealth (https://oncohealth.us/), non-oncologic cases to Avalon (fax 813-751-3760 or call 844-227-5769)
3. Update prior authorization workflows in billing software to reflect new authorization pathways
4. Train front-desk, clinical, and billing staff on new genetic testing authorization process
By March 31, 2026: Billing team must:
1. Implement authorization requirements for Medical 259 (Prescription Digital Therapeutics and Devices) across all applicable service lines
2. Update DME 31 (Mechanical Stretching Devices) billing procedures to reflect revised policy
3. Implement Surgical 121 (Lumbar Laminectomy) authorization changes
4. Configure system for Evolent Advanced Imaging Guidelines effective April 1, 2026, with exception: CPT 75574 (Coronary Artery CTA) now requires documentation that results are necessary for clinical decision-making
Consequences of inaction: Claims submitted through incorrect authorization channels (e.g., genetic testing through MCG instead of OncoHealth/Avalon) will be denied. Advanced imaging claims without proper authorization and clinical justification per Evolent guidelines will be rejected.