What insurance policy changes were tracked in 2026?

In 2026 we tracked 39,526 policy changes across major U.S. health insurance payers. Changes include prior authorization rule updates, billing-code coverage modifications, fee schedule revisions, and plan-type policy changes.

How do I find 2026 policy changes for my specialty or state?

Use the related-hub links below the list to filter by provider, state, or specialty. You can also browse the full /changes feed and use pagination to reach the 2026 date range.

PAYER POLICY CHANGES

Insurance Policy Changes in 2026

All insurance policy changes we tracked in 2026. Each entry is AI-summarized with an impact rating and linked billing codes so you can quickly assess what matters to your practice. Showing the 50 most recent of 39,526 total changes for 2026.

Medi-Cal · Effective Jan 1, 2027High impact
FQHC and RHC Policy for UIS Members Transitioning to Fee-for-Service on January 1, 2027
Effective January 1, 2027, Medi-Cal members with Unsatisfactory Immigration Status move from Medi-Cal managed care plans to Medi-Cal fee-for-service, so FQHC and RHC claims for these members must go directly to the Medi-Cal fiscal intermediary rather than to the former plan. Effective for services on or after January 1, 2027, claims sent to the former plan or to the FI for an MCP differential (wrap) rate will be denied, and from July 1, 2027, emergency and pregnancy-related services for these members are reimbursed only at the PPS rate with the appropriate diagnosis code and emergency indicator.
Medi-Cal · Effective Jan 1, 2027Medium impact
Medi-Cal Fee-for-Service Provider Toolkit for UIS Transition is Available
Medi-Cal published a provider toolkit to help providers prepare for the federal requirements starting January 1, 2027, under which Medi-Cal members with Unsatisfactory Immigration Status (UIS) who receive care through Medi-Cal fee-for-service will transition out of managed care. The toolkit covers accepting new patients, enrolling in Medi-Cal fee-for-service, verifying eligibility, TAR continuity, transportation services, and services available in both managed care and fee-for-service, and is posted on the Ordering, Referring and Prescribing and Medi-Cal Managed Care to Fee-for-Service Transition web pages.
Medi-Cal · Effective Jul 1, 2026Medium impact
Fee Schedule Rate Update for 2026 Codes
Medi-Cal updated payment rates for selected procedure codes, effective for dates of service on or after July 1, 2026, with the updated rates posted on the Medi-Cal Rates page under Adjusted State Plan Amendment Rates. Medi-Cal will run an Erroneous Payment Correction to reprocess claims at the new rates for dates of service on or after the billing policy's effective date, including claims submitted under earlier guidance that were paid at prior rates.
BCBS Oklahoma · Identified Nov 7, 2026Low impact
Verify Your Directory Information Every 90 Days
Blue Cross and Blue Shield of Oklahoma published a November 6, 2026 notice that federal law requires provider directory information (name, address, phone, specialty, digital contact information) to be verified every 90 days, even without changes. Practices can verify through the Qualified Health Plans directory, Availity Essentials Provider Data Management, or the Demographic Change Form, and must update changes with the payer, the CAQH Provider Data Portal, and the NPPES NPI Registry.
Cigna · Identified Nov 7, 2026Low impact
Cigna Healthcare introduces Health Sense® to connect health guidance, benefits and support
Published October 6, 2026: Cigna Healthcare announced Health Sense, a connected patient experience and clinical support model built on existing myCigna, customer service, care management and clinical support services. Cigna says it will begin rolling out Health Sense in the first quarter of 2027, initially supporting oncology and cardiometabolic health needs, and that it does not diagnose, prescribe, modify treatment or replace the treating provider. The content does not describe any new billing, coding, prior authorization or claims requirement for practices.
Cigna · Effective Oct 31, 2026High impact
Summary of Provider Newsroom U.S. commercial medical articles
Cigna Healthcare's October 2026 Provider Newsroom recap lists several U.S. commercial items, most notably a prior authorization portal change: effective October 31, 2026, EviCore by Evernorth will move prior authorization requests for certain Cigna Healthcare services from the MedSolutions portal to the CareCore portal on EviCore.com. Other items cover drug list updates for Cigna Specialty Care Options and Cigna Pathwell Specialty, a Specialty Medical Injectables reimbursement restriction requiring dispensing and claim submission through a Cigna-contracted specialty pharmacy, and a 270/271 eligibility transaction enhancement.
Cigna · Identified Nov 7, 2026Low impact
Summary of Provider Newsroom behavioral health articles
Evernorth published a monthly recap of its October 2026 behavioral health Provider Newsroom articles, covering continuity and coordination of care between medical and behavioral health providers, completion of the third and final phase of CAQH CORE recertification enhancements to the 270/271 eligibility and benefits transaction (applying to medical, dental, and behavioral health providers, dated October 5, 2026), and California and New Mexico language assistance program requirements. Billing teams should note the completed 270/271 enhancement for eligibility verification workflows and review the linked articles for any operational steps.
Ambetter · Effective Jan 1, 2027Medium impact
Ambetter Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Published June 22, 2026: Ambetter Health announced that 46 listed HCPCS H codes will no longer be covered beginning January 1, 2027, while HCPCS H0006 will become covered on that same date. Billing teams should identify claims and scheduled services using the listed H codes for January 2027 dates of service and prepare charge entry and provider notification accordingly.
Ambetter · Effective Dec 6, 2026High impact
Leveling for Facility Claims
Ambetter from WellCare of Kentucky will apply national CPT guidelines to the coding of outpatient emergency department E&M levels for facility claims beginning 12/06/2026. Under the payer's comparative peer risk adjustment process, E&M claim lines will be recoded to the corrected level, with reimbursement at the highest level whose criteria are met, based on facility resources such as nursing time, clinical staff effort, supplies, equipment, and overhead rather than provider cognitive work. The payer's policy CC.PP.80 replaces the previous Optum EDC Analyzer.
Ambetter · Identified Nov 7, 2026Medium impact
Enhancing the Claims Experience in Availity Essentials
Beginning in December 2026, providers using Availity Essentials will be able to submit claim disputes/reconsiderations and appeals in the portal, download determination letters and notices, and access previously submitted attachments. Attachment capacity per request expands to 600 MB total, with up to 10 files per request at 60 MB per file. Access to these tools requires the Claim Status role, and Availity is offering free live training sessions on December 8 and December 10, 2026.
Oregon Health Plan · Effective Jan 1, 2027Medium impact
Healthier Oregon Transition Data Guidance for Prior Authorizations
Oregon's Office of Health Policy (OHA) directed coordinated care organizations (CCOs) to submit prior authorization data for Healthier Oregon members transitioning to the Oregon Health Plan Open Card program, covering approved prior authorizations for prescription, medical, behavioral and oral health services to be rendered on or after Jan. 1, 2027, plus program exception approvals. Practices in Oregon that serve these members should expect prior authorizations to be entered into fee-for-service claims processing on the dates listed, so billing staff should confirm which active authorizations carry 2027 effective dates and that claims reference them correctly.
Horizon BCBS NJ · Identified Nov 7, 2026Low impact
Mailing Address Update: BlueCard® Claims, Appeals, Medical Records
Published June 2024: Horizon BCBSNJ created a new mailing address, Horizon BCBSNJ BlueCard Claims, Three Penn Plaza East, Suite 1, Newark, NJ 07105-2248, for BlueCard claims, appeals and medical records from practices and facilities. Billing teams should send these items to the new address rather than the previous BlueCard PO Box 1301, and the USPS will forward mail sent to PO Box 1301 through the end of 2026.
Geisinger Health Plan · Effective Jan 1, 2027Medium impact
Preparing for new interoperability enhancements coming in 2027
Geisinger Health Plan (GHP) announced it will implement CMS-0057-F interoperability requirements, including a Provider Access API for in-network providers and a Prior Authorization API for electronic prior authorization exchange, with compliance beginning January 1, 2027 for Geisinger Gold (Medicare Advantage and Medicaid managed care), GHP Family, GHP Kids, Geisinger Marketplace, and FEHB products. Providers and their technology partners will need to register through the GHP Developer Portal and confirm a treatment relationship before member data can be requested; the publication says prior authorization requirements and decision criteria are unchanged.
SC Medicaid - SCDHHS · Effective Dec 15, 2026Medium impact
Updated Prior Authorization Expansion on Physician-administered Drugs
South Carolina Medicaid will require prior authorization for a list of physician-administered drugs when given to fee-for-service Healthy Connections Medicaid members. The drug list is published in the procedure codes section of the Physicians Services Provider Manual and is updated with the added drugs beginning December 15, 2026.
Humana · Identified Nov 7, 2026Medium impact
Quviviq (daridorexant) (Revised)
Humana published a revised Medicare step therapy policy for Quviviq (daridorexant) tablets for insomnia, with a revision date of October 28, 2026. Members must have previously tried, been contraindicated to, or been intolerant of Belsomra (suvorexant) or trazodone tablets before Quviviq is covered, and Quviviq is contraindicated in patients with narcolepsy. The policy was originally effective January 1, 2024.
BCBS Illinois · Identified Nov 7, 2026Medium impact
Verify Your Directory Information Every 90 Days
Blue Cross Blue Shield of Illinois requires contracted providers' directory information to be verified at least every 90 days, even when nothing has changed, citing Illinois House Bill 5395 and the federal Consolidated Appropriations Act of 2021. Commercial provider groups should request or submit rosters every 90 days, facilities and ancillary providers should use the Demographic Change Form, and HMO medical groups and IPAs continue monthly roster submission.
Kaiser Permanente · Identified Nov 7, 2026Low impact
November 6, 2026 Kaiser Permanente and Risant Health Q3 2026 financial update Kaiser Permanente and Risant Health continued to provide high-quality, …
Kaiser Permanente and Risant Health published their Q3 2026 financial update on November 6, 2026, reporting on financial results and continued high-quality care. The item is a corporate financial announcement and does not describe any change to coverage, prior authorization, billing codes, or claims requirements for providers.
L.A. Care Health Plan · Effective Oct 28, 2026High impact
Updated HCPCS Codes Requiring Prior Authorization – Medicare
L.A. Care Health Plan now requires prior authorization for eight HCPCS codes for its Medicare members, following CMS's addition of those codes to the DMEPOS Required Prior Authorization List, effective October 28, 2026. Separately, 22 HCPCS codes were added to the Required Face-to-Face Encounter and Written Order Prior to Delivery list effective the same date, requiring a documented face-to-face encounter within six months before the written order and communication of the order to the supplier before delivery.
BCBS Texas · Identified Nov 7, 2026Low impact
Verify Your Directory Information Every 90 Days
Blue Cross and Blue Shield of Texas published a reminder that provider directory information must be verified every 90 days, even if nothing has changed, and that changes to name, address, phone, specialty, or digital contact details must be updated with the payer, the CAQH Provider Data Portal, and the NPI Registry. Practices can verify through Availity Essentials Provider Data Management or the Demographic Change Form, and Texas Medicaid providers must update through PEMS.
Ohio Medicaid · Effective Nov 2, 2026Medium impact
5160-1-05.3 - Payment for "Medicare Part B" cost sharing. (Amend/Revise)
Ohio Department of Medicaid filed a revised version (Amendment, effective 11/02/2026 per the filing record) of rule 5160-1-05.3, which governs payment for Medicare Part B cost sharing. The filing record shows the revision was filed 11/06/2026; the excerpt does not provide the substantive payment text, so the specific changes to cost-sharing payment cannot be identified from it.
Aetna · Identified Nov 7, 2026Medium impact
In Vivo Analysis of Gastro-Intestinal and Urothelial Lesions (CPB 0783, reviewed 2026-10-27)
Aetna's Clinical Policy Bulletin 0783 (reviewed 2026-10-27) confirms that in vivo analysis technologies for gastrointestinal and urothelial lesions, including confocal laser endomicroscopy, narrow-band imaging, chromoendoscopy and optical biopsy systems, are considered experimental, investigational or unproven for the listed indications. Claims for these services with the listed CPT codes (such as 43206, 43252 and +0397T) and ICD-10 diagnoses will be denied under this policy, so billing staff should review how these services are coded and documented before submission.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Vitamin D Testing
UnitedHealthcare's Medicare Advantage Vitamin D Testing medical policy, in the November 2026 bulletin effective 2026-11-01, removed ICD-10 diagnosis codes C88.4, Z79.60, Z79.61, Z79.620 through Z79.624, Z79.630 through Z79.634, Z79.64, and Z79.69 from the applicable codes list, and updated the CMS related documents list and clinical evidence references. Billing teams should stop relying on the removed diagnosis codes when submitting Vitamin D testing claims for Medicare Advantage members and confirm that remaining claims carry a supported diagnosis.
UnitedHealthcare · Effective Nov 1, 2026Low impact
Uterine Services Procedures
UnitedHealthcare's Medicare Advantage medical policy bulletin for November 2026 revised the Uterine Services Procedures coverage rationale. The coverage language on MRI-guided focused ultrasound ablation now states that Medicare does not have a National Coverage Determination for that procedure, replacing the prior reference to MRI-guided cryoablation. Billing teams should update any reference materials or coverage notes for uterine ablation services billed to these Medicare Advantage plans.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Tier 2 Molecular Pathology Procedures
UnitedHealthcare's November 2026 Medicare Advantage medical policy update for Tier 2 Molecular Pathology Procedures changes the applicable codes and removes diagnosis code Z59.7 from the non-covered diagnosis list. Billing teams should review claims for these molecular pathology procedures against the updated applicable codes and diagnosis edits.
UnitedHealthcare · Effective Nov 1, 2026Low impact
Skilled Nursing Facility, Rehabilitation, Long-Term Acute Care Hospital, and Private Duty Nursing
UnitedHealthcare's Medicare Advantage medical policy bulletin for November 2026 updates the skilled nursing facility, rehabilitation, long-term acute care hospital, and private duty nursing policy, effective 2026-11-01. The update notes that CPT codes 92507, 92508, and 92526 were deleted September 30, 2026, and refreshes the list of related CMS documents in the Medicare Coverage Database.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Radiologic Diagnostic Procedures
UnitedHealthcare's November 2026 Medicare Advantage bulletin revises the Radiologic Diagnostic Procedures policy effective 2026-12-01: amyloid brain PET coverage language in dementia and neurodegenerative disease was removed, CPT 78811 and 78814 were removed from the Positron Emission Tomography (Amyloid Brain) section, and Z59.7 was removed from the non-covered diagnosis codes. The bulletin also annotates a list of other nuclear medicine CPT codes as deleted (78012 through 78999 series codes marked 'deleted Dec. 31, 2025', and 78499 marked 'deleted Sep. 30, 2026') and removes a related-policy link to the GI services policy. Billing teams should update code tables and claim-entry edits so these codes are no longer used for these members.
UnitedHealthcare · Effective Nov 1, 2026Low impact
Platelet Rich Plasma Therapies
UnitedHealthcare's Medicare Advantage bulletin for November 2026 updated its Platelet Rich Plasma Therapies medical policy by adding reference links to CMS transmittals and MLN Matters articles tied to NCD 270.3 (Blood-Derived Products for Chronic, Non-Healing Wounds) and to ICD-10 and other coding revisions to National Coverage Determinations, and by refreshing the FDA section and the list of Medicare Coverage Database documents. The changes are reference and documentation updates rather than new coverage criteria stated in the text provided. Billing teams should review the updated policy reference set for wound-related and PRP-related services billed to these Medicare Advantage plans.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Pain Management
UnitedHealthcare Medicare Advantage revised its Pain Management medical policy in the November 2026 bulletin, effective 2026-11-01. Changes include renaming the Pulsed Radiofrequency Ablation heading to a non-thermal method, updating LCD/LCA language to state that LCDs/LCAs exist for all states, removing a cross-reference to the Commercial Ablative Treatment for Spinal Pain policy, adding a pointer to the Commercial Omnibus Codes policy for CPT 0440T, 0441T and 0442T under percutaneous cryoneurolysis, revising the CPT 22899 description for Pulsed and Cooled RFA, and refreshing the CMS-related documents list.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Molecular Pathology/Genetic Testing Reported with Unlisted Codes
UnitedHealthcare's Medicare Advantage medical policy bulletin for November 2026 revised the policy on molecular pathology and genetic testing reported with unlisted codes, removing diagnosis code Z59.7 from the non-covered diagnosis codes list. Billing teams should update diagnosis and claim edit lists for these unlisted genetic and molecular testing claims to reflect the removal.
UnitedHealthcare · Effective Nov 1, 2026High impact
Medications/Drugs (Outpatient/Part B)
UnitedHealthcare's Medicare Advantage Medical Policy for Medications/Drugs (Outpatient/Part B) was revised with an effective date of 2026-11-01. Eight specific drugs now require a pre-service review (Review at Launch) before they are provided: Ahzantive (aflibercept-mrbb), Enzeevu (aflibercept-abzv), Eydenzelt (aflibercept-boav), Fayuvi (rebisufligene etisparvovec-hopf), Isembyld (apitegromab-mstn), Opuviz (aflibercept-yszy), Yesafili (aflibercept-jbvf), and Zanvastro (zilganersen). The revision also clarifies that oral anti-cancer medications may be covered under a member's Part D plan rather than this policy, changes the Antigens heading to 'antigens' only, and updates the homebound definition.
UnitedHealthcare · Effective Jan 1, 2027Low impact
Hospital, Emergency, and Ambulance Services
UnitedHealthcare's Medicare Advantage medical policy for hospital, emergency, and ambulance services was revised in the November 2026 bulletin, effective 2027-01-01. Inpatient hospital coverage rationale now links to the Two Midnight Rule Fact Sheet in place of the older CMS FAQ on midnight inpatient admission guidance, and the outpatient hospital section points to the CY 2026 OPPS/ASC final rule. Billing teams should update their internal reference materials and admission-status and outpatient coding guidance to match the revised links.
UnitedHealthcare · Effective Nov 1, 2026Low impact
Gender Dysphoria and Gender Reassignment Surgery
UnitedHealthcare's Medicare Advantage medical policy for gender dysphoria and gender reassignment surgery was updated in the November 2026 bulletin, adding ICD-10 diagnosis codes F64.A and Z87.893. Billing teams should update diagnosis code lists and claim edits so claims for these services carry the newly added codes where applicable.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Durable Medical Equipment (DME), Prosthetics, Orthotics (Non-Foot Orthotics), Nutritional Therapy, and Medical Supplies Grid
UnitedHealthcare's Medicare Advantage DME, prosthetics, orthotics and supplies grid is revised effective 2026-12-01: several items now defer to other coverage policies (foot cradles, insulin pumps, bead beds/egg crates, air-fluidized beds), a face-to-face encounter requirement is added for manual wheelchairs, oxygen, and ventilators, pediatric cribs language is removed, and several HCPCS codes are added or removed for artificial upper limbs, CPAP devices, lifts, lymphedema items and LLPS splints. The practice's billing team should update charge entry and claim edits for the changed code lists and confirm documentation for face-to-face encounters before dispensing these items to Medicare Advantage members.
UnitedHealthcare · Effective Nov 1, 2026High impact
Clinical Diagnostic Laboratory Services
UnitedHealthcare's Medicare Advantage November 2026 update to Clinical Diagnostic Laboratory Services adds 0631U through 0659U to the CPT/HCPCS codes that are not covered when submitted with a screening diagnosis, and removes 0167U, 0204U, 0206U, 0207U, 0289U, 0393U, 0396U, 0412U, 0443U, 0479U, 0503U, 0547U, 0568U, 0596U, 0616U, and 83884 from that list. It also adds a coding clarification that ICD-10 codes Z82.49 and Z83.2 are excluded from non-coverage for CPT 81240 and 81241, removes Z59.7 from the non-covered diagnosis codes, and notes that 0556U, 0557U, and 0585U were deleted Sep. 30, 2026. Billing teams should update claim edits and screening-diagnosis workflows for these codes.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Ambulatory Electrocardiographic (AECG) Monitoring
UnitedHealthcare's Medicare Advantage bulletin for November 2026 updated its Ambulatory Electrocardiographic (AECG) Monitoring policy, adding diagnosis codes I42.00, I42.01, I42.09, I42.81, I42.89, I47.22, I49.81, I49.82, and I49.89 to the applicable-codes list for CPT 93224–93229, 93241–93248, 93268, 93270–93272, and 0937T–0940T. The bulletin also notes that I42.0 and I49.8 were deleted Sep. 30, 2026, and the coverage document list was refreshed. Billing teams should update diagnosis coding for AECG monitoring claims to use the newly listed codes.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Saphnelo® (Anifrolumab-Fnia)
Starting 2027-01-01, UnitedHealthcare Community Plan of Tennessee revised its Saphnelo (anifrolumab-fnia) IV medical policy for moderate to severe systemic lupus erythematosus. Initial and continuation requests now require a prescriber attestation, with explanation, that the patient or caregiver cannot be trained or is physically unable to self-administer Saphnelo or Benlysta, along with a history of failure, contraindication, or intolerance to Benlysta IV or SQ for initial therapy. Saphnelo pen for self-administered subcutaneous injection falls under the pharmacy benefit rather than this policy.
UnitedHealthcare · Effective Dec 1, 2026Low impact
Pasatru ™ (Garetosmab-Grts)
UnitedHealthcare Community Plan of Tennessee added a Medicaid medical benefit drug policy for Pasatru (garetosmab-grts), effective 2026-12-01, covering treatment of fibrodysplasia ossificans progressiva (FOP). Initial therapy requires patients over 18, a confirmed FOP diagnosis, chart notes and ACVR1 genetic testing, use to reduce new heterotopic ossification lesions and flare-ups, no combination with Sohonos (palovarotene), prescribing by or in consultation with an FOP expert, dosing per FDA labeling, and initial authorization of no more than 12 months. Continuation requires documented positive clinical response and the same conditions, with reauthorization of no more than 12 months.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Omalizumab
Effective 2026-12-01, UnitedHealthcare's Community Plan of Tennessee Medicaid policy for omalizumab is retitled from Xolair to omalizumab and now covers Omlyclo (omalizumab-igec), Xolair, and any FDA-approved, launched omalizumab biosimilar not named in the policy, with unlisted biosimilars treated as non-preferred until UnitedHealthcare reviews them. Omalizumab for healthcare-professional-administered subcutaneous injection falls under this medical benefit policy, while self-administered omalizumab is obtained under the pharmacy benefit, and HCPCS code Q5154 has been added.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease
UnitedHealthcare Community Plan of Tennessee revised its Medicaid medical benefit policy for Alzheimer's amyloid-directed monoclonal antibodies (Leqembi and Kisunla), effective 2026-12-01. Continuation-of-therapy criteria now require an Alzheimer's diagnosis and MRI ARIA monitoring per FDA labeling, and the prior removed the requirement for chart notes confirming follow-up MRI; a new Leqembi intravenous dosing criterion was added, and Leqembi IQLIK self-administered subcutaneous injection is routed to the pharmacy benefit unless the member's plan document says otherwise.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Maximum Dosage and Frequency
UnitedHealthcare Community Plan of Tennessee revised its Maximum Dosage and Frequency medical benefit drug policy, updating the maximum allowed HCPCS units and frequencies, adding Exdensur (depemokimab) and Spinraza (nusinersen), adding HCPCS codes J2326 and J2361, and revising the descriptions for Q5136 and Q5157. Billing teams should update claim edits and charge entry so units and dosing frequency for these drugs stay within the new limits, and should verify that services billed beyond the maximum allowed quantities are documented with the clinical rationale the policy requires.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Ilaris ® (Canakinumab)
UnitedHealthcare Community Plan of Tennessee updated its Ilaris (canakinumab) medical benefit drug policy in its November 2026 bulletin. For Still's disease, including adult-onset Still's disease and systemic juvenile idiopathic arthritis, coverage now requires that the patient not be receiving Ilaris in combination with another systemic targeted immunomodulator for the same indication.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Hereditary Angioedema (HAE), Treatment and Prophylaxis
UnitedHealthcare Community Plan of Tennessee updated its Hereditary Angioedema (HAE) treatment and prophylaxis medical benefit drug policy in its November 2026 bulletin, with the status listed as updated and an effective date of 2026-11-01. The update revises the list of applicable CPT codes to reflect quarterly edits and adds codes 0678U and 0679U. Billing teams should review HAE-related charges for these Tennessee Medicaid members and update charge entry so claims carry the codes the policy now lists.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Genglycos ™ (Pariglasgene Brecaparvovec-Opnr)
UnitedHealthcare Community Plan of Tennessee added a new medical benefit drug policy for Genglycos (pariglasgene brecaparvovec-opnr) for Medicaid members, effective 2026-12-01. Coverage is limited to patients 8 years or older with glycogen storage disease type Ia who meet diagnosis confirmation, cornstarch therapy, AAV8 antibody, prior gene therapy, specialist, admission, labeling, and single-lifetime authorization limits, with authorization valid for no more than 45 days from approval.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
FcRn Blockers
UnitedHealthcare Community Plan of Tennessee revised its FcRn Blockers medical benefit drug policy, with a stated effective date of 2027-01-01. Imaavy (nipocalimab-aahu) is now covered as proven and medically necessary for warm autoimmune hemolytic anemia (wAIHA) in adults and children 12 and older who are currently or were previously treated with corticosteroids, subject to documentation, prescriber, dosing and combination-therapy criteria; ICD-10 code D59.11 was added to the policy's applicable codes.
UnitedHealthcare · Effective Jan 1, 2027High impact
Denosumab
Effective 2027-01-01, UnitedHealthcare Community Plan of Tennessee revised its Medicaid medical benefit policy for denosumab. Jubereq and Osvyrti are now preferred products covered under the Diagnosis-Specific Criteria, while Boncresa, Oziltus, and Ponlimsi are non-preferred products covered only if the Preferred Product Criteria and Diagnosis-Specific Criteria are both met. The policy also adds a very-high-fracture-risk criterion for initial osteoporosis therapy and adds HCPCS codes Q5166, Q5171, and Q5173.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Video Electroencephalographic (vEEG) Monitoring and Recording (for Tennessee Only)
UnitedHealthcare Community Plan of Tennessee retired its medical policy for video electroencephalographic (vEEG) monitoring and recording, effective 2026-11-01, so these services no longer require clinical review under that policy. Billing teams should stop routing vEEG requests for Tennessee Medicaid members through the retired policy's review pathway and update scheduling and prior authorization workflows to reflect the retirement.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Treatment of Temporomandibular Joint Disorders (for Tennessee Only)
UnitedHealthcare Community Plan of Tennessee revised its Treatment of Temporomandibular Joint Disorders medical policy for Tennessee Medicaid members, effective 2026-12-01. TMJ surgical services (arthroscopy, discectomy, reconstruction) are now assessed against the InterQual CP Arthroplasty TMJ criteria instead of the prior InterQual procedures reference, and CPT 21060, 21247, 29800 and 29804 were removed from the applicable codes list. Multiple occlusal splints, jaw mobility stretching devices and epigenetic appliances remain listed as not medically necessary.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver (for Tennessee Only)
Effective 2026-12-01, UnitedHealthcare Community Plan of Tennessee revised its Medicaid medical policy for transarterial radioembolization (TARE)/selective internal radiation therapy (SIRT) using yttrium-90 microspheres for liver malignancies, applicable to Tennessee members 19 years of age or older. The proven and medically necessary indications for patients with ECOG status 0, 1, or 2 were updated, most notably changing the uveal melanoma indication to read "metastasis from uveal melanoma when confined to the liver" (previously "uveal/ocular melanoma"), and the TARE definition was updated; all other indications are considered unproven and not medically necessary.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Surgery of the Elbow (for Tennessee Only)
UnitedHealthcare Community Plan of Tennessee retired its Surgery of the Elbow medical policy, effective 2026-11-01, so elbow surgery for Tennessee Medicaid members no longer requires clinical review under that policy. Billing teams should update prior authorization tracking and scheduling workflows for these members so that claims for elbow surgery are no longer held for a review that no longer applies.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Obstructive and Central Sleep Apnea Treatment (for Tennessee Only)
UnitedHealthcare Community Plan of Tennessee revised its Medicaid medical policy on obstructive and central sleep apnea treatment, effective 2026-12-01. Revised coverage adds radiofrequency ablation of the soft palate and/or tongue base to the list of unproven and not medically necessary surgical procedures, and adds HCPCS code L8697 to the applicable codes list. Removable oral appliances require documentation that PAP therapy failed or was not tolerated, and the policy defines the diagnosis requirements before treatment begins.

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FQHC and RHC Policy for UIS Members Transitioning to Fee-for-Service on January 1, 2027

Medi-Cal Fee-for-Service Provider Toolkit for UIS Transition is Available

Fee Schedule Rate Update for 2026 Codes

Verify Your Directory Information Every 90 Days

Cigna Healthcare introduces Health Sense® to connect health guidance, benefits and support

Summary of Provider Newsroom U.S. commercial medical articles

Summary of Provider Newsroom behavioral health articles

Ambetter Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Leveling for Facility Claims

Enhancing the Claims Experience in Availity Essentials

Healthier Oregon Transition Data Guidance for Prior Authorizations

Mailing Address Update: BlueCard® Claims, Appeals, Medical Records

Preparing for new interoperability enhancements coming in 2027

Updated Prior Authorization Expansion on Physician-administered Drugs

Quviviq (daridorexant) (Revised)

Verify Your Directory Information Every 90 Days

November 6, 2026 Kaiser Permanente and Risant Health Q3 2026 financial update Kaiser Permanente and Risant Health continued to provide high-quality, …

Updated HCPCS Codes Requiring Prior Authorization – Medicare

Verify Your Directory Information Every 90 Days

5160-1-05.3 - Payment for "Medicare Part B" cost sharing. (Amend/Revise)

In Vivo Analysis of Gastro-Intestinal and Urothelial Lesions (CPB 0783, reviewed 2026-10-27)

Vitamin D Testing

Uterine Services Procedures

Tier 2 Molecular Pathology Procedures

Skilled Nursing Facility, Rehabilitation, Long-Term Acute Care Hospital, and Private Duty Nursing

Radiologic Diagnostic Procedures

Platelet Rich Plasma Therapies

Pain Management

Molecular Pathology/Genetic Testing Reported with Unlisted Codes

Medications/Drugs (Outpatient/Part B)

Hospital, Emergency, and Ambulance Services

Gender Dysphoria and Gender Reassignment Surgery

Durable Medical Equipment (DME), Prosthetics, Orthotics (Non-Foot Orthotics), Nutritional Therapy, and Medical Supplies Grid

Clinical Diagnostic Laboratory Services

Ambulatory Electrocardiographic (AECG) Monitoring

Saphnelo® (Anifrolumab-Fnia)

Pasatru ™ (Garetosmab-Grts)

Omalizumab

Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease

Maximum Dosage and Frequency

Ilaris ® (Canakinumab)

Hereditary Angioedema (HAE), Treatment and Prophylaxis

Genglycos ™ (Pariglasgene Brecaparvovec-Opnr)

FcRn Blockers

Denosumab

Video Electroencephalographic (vEEG) Monitoring and Recording (for Tennessee Only)

Treatment of Temporomandibular Joint Disorders (for Tennessee Only)

Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver (for Tennessee Only)

Surgery of the Elbow (for Tennessee Only)

Obstructive and Central Sleep Apnea Treatment (for Tennessee Only)