Continuing from page 1. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.
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'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'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 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'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'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'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'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'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'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'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.
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 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.
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 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 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 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 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 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 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.
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 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 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.
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 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.
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