CommercialPrior AuthHigh impact
Medical and Clinical Policy Update - Effective December 1, 2025
Sentara Health Plans·Orthopedics, General Surgery, Neurosurgery +3 more·Medical Policy
Effective date
Dec 1, 2025
We identified it
Sep 19, 2025
Summary
Sentara Health Plans has updated 16 medical policies effective December 1, 2025, including archiving policies (moving to MCG guidelines or other policies), revising existing policies, and reviewing others. Key changes affect spinal surgery procedures (lumbar fusion, discectomy, laminectomy, cervical laminectomy), cardiac procedures (hemodynamic monitoring, mitral valve implantation), and orthopedic surgeries. Billing teams must identify which of these procedures your practice performs and verify updated coverage criteria and prior authorization requirements through the updated Prior Authorization List (PAL).
Action Required
By November 24, 2025: (1) Billing team must access pal.sentarahealthplans.com to review the updated Prior Authorization List for all affected procedure codes. (2) Cross-reference your practice's current procedure mix against the 16 updated policies, particularly: Lumbar Fusion (Surgical 118), Lumbar Discectomy (Surgical 120), Lumbar Laminectomy (Surgical 121), Cervical Laminectomy (Surgical 122), Implantable Hemodynamic Monitoring (Medical 317), Surgical-Assisted Liposuction (Surgical 131), Spinal Arthroplasty (Surgical 35), and Intraoperative Neurophysiological Monitoring (Surgical 40). (3) For archived policies (DME 242, Medical 108, Medical 293, Surgical 127, Surgical 136), immediately cease using those policy numbers and transition to replacement guidelines noted in the status column. (4) Update your billing software and prior authorization workflows to reflect the new requirements no later than December 1, 2025. (5) Notify clinical staff and providers of policy changes affecting their specialties. Failure to implement updates by the effective date will result in claim denials and authorization failures.