PAYER POLICY CHANGES

All Insurance Policy Changes (Page 3)

Continuing from page 2. 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 · 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.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Glaucoma Surgical Treatments (for Tennessee Only)
UnitedHealthcare Community Plan of Tennessee updated its Glaucoma Surgical Treatments medical policy in the November 2026 bulletin, effective 2026-11-01. The coverage rationale now states that all other FDA-approved laser procedures not listed as proven and medically necessary are unproven and not medically necessary for any type of glaucoma. Billing teams treating glaucoma patients with Tennessee Medicaid coverage should review laser procedure scheduling and charge entry against this rationale.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Genetic Testing for Neurological Disorders (for Tennessee Only)
UnitedHealthcare Community Plan of Tennessee revised its Genetic Testing for Neurological Disorders medical policy for Tennessee Medicaid members, effective 2026-11-01. The update removes cross-references to the Chromosome Microarray Testing and Genetic Testing for Cardiac Disease policies, rewords the multi-gene panel language to 'Targeted Panel testing of five or more genes,' and drops the Whole Exome Sequencing and Whole Genome Sequencing definitions, with the description, evidence, and reference sections refreshed. Billing teams should align charge entry and documentation for these services with the reworded panel criteria for Tennessee Medicaid claims.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Saphnelo® (Anifrolumab-Fnia)
UnitedHealthcare Community Plan of Pennsylvania revised its Saphnelo (anifrolumab-fnia) IV medical benefit drug policy, effective 2027-01-01. Starting then, coverage for moderate to severe SLE requires 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, and the policy continues to exclude severe active CNS lupus, severe active lupus nephritis, and combination use with other biologics.
UnitedHealthcare · Effective Dec 1, 2026Low impact
Pasatru™ (Garetosmab-Grts)
UnitedHealthcare Community Plan of Pennsylvania (Medicaid) added a medical policy for Pasatru (garetosmab-grts) for fibrodysplasia ossificans progressive (FOP), effective 2026-12-01. Initial therapy requires patients over 18, a FOP diagnosis, chart notes documenting clinical signs and symptoms, genetic testing confirming an ACVR1 mutation, prescribing by or in consultation with an FOP expert, dosing per FDA labeling, no combined use with Sohonos (palovarotene), and authorization for no more than 12 months; continuation requires documented positive clinical response with similar limits.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Genglycos ™ (Pariglasgene Brecaparvovec-Opnr)
UnitedHealthcare Community Plan of Pennsylvania added a Medicaid medical benefit policy for Genglycos (pariglasgene brecaparvovec-opnr) for glycogen storage disease type Ia, effective 2026-12-01. Coverage is limited to patients 8 years or older with a confirmed diagnosis, documented by bi-allelic G6PC variants or absent G6Pase activity on liver biopsy, who are on cornstarch therapy, have no detectable AAV8 antibodies, have never received gene therapy for GSDIa, are managed by or with a metabolic specialist, and are dosed per FDA labeling. Authorization covers one lifetime treatment and no more than 45 days from approval.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
FcRn Blockers
Medicaid members in Pennsylvania under the UnitedHealthcare Community Plan will see revised FcRn blocker coverage criteria effective 2027-01-01. Imaavy (nipocalimab-aahu) is now described as proven and medically necessary for warm autoimmune hemolytic anemia (wAIHA) in patients 12 years and older who are currently or were previously treated with corticosteroids, subject to documented diagnosis, prior therapy and prescriber requirements. ICD-10 code D59.11 was added to the applicable codes.
UnitedHealthcare · Effective Nov 1, 2026Low impact
Video Electroencephalographic (vEEG) Monitoring and Recording (for Pennsylvania Only)
UnitedHealthcare Community Plan of Pennsylvania retired its Video Electroencephalographic (vEEG) Monitoring and Recording medical policy for Pennsylvania Medicaid members, effective 2026-11-01. Vídeo EEG monitoring and recording no longer requires clinical review under this plan's policy, so the billing team should stop routing these requests through the clinical review workflow for these members.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Surgery of the Elbow (for Pennsylvania Only)
UnitedHealthcare Community Plan of Pennsylvania retired its Surgery of the Elbow medical policy for Pennsylvania Medicaid members, effective 2026-11-01, so surgery of the elbow no longer requires clinical review under that policy. Billing teams should stop routing elbow surgery cases for this plan through the retired clinical review criteria and confirm the practice's prior authorization tracker reflects the change.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Cardiovascular Disease Risk Tests (for Pennsylvania Only)
UnitedHealthcare Community Plan of Pennsylvania revised its Cardiovascular Disease Risk Tests medical policy for Pennsylvania Medicaid members, effective 2026-12-01. Subfractions or particle size advanced lipoprotein analysis is now listed as unproven and not medically necessary for cardiovascular risk, the list adds noninvasive point-of-care cardiac diagnostic platforms (such as CorVista) for predicting coronary artery disease, pulmonary hypertension, or pulmonary capillary wedge pressure, and CPT 83695 has been removed from the applicable codes.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Breast Imaging for Screening and Diagnosing Cancer (for Pennsylvania Only)
UnitedHealthcare Community Plan of Pennsylvania revised its Medicaid medical policy for breast imaging for screening and diagnosing cancer, effective 2026-12-01. Magnetic resonance elastography and molecular breast imaging are now listed as unproven and not medically necessary, with the molecular imaging entry narrowed to routine screening in normal or high-risk individuals and positron emission mammography. The coverage rationale also adds a specific MRI-of-the-breast entry for elastography, and the criteria for proven high-risk breast MRI are unchanged in the text provided.
UnitedHealthcare · Effective Dec 1, 2026Low impact
White Blood Cell Colony Stimulating Factors (for Ohio Only)
UnitedHealthcare Community Plan of Ohio published its November 2026 Medical Benefit Drug Policy update for White Blood Cell Colony Stimulating Factors (Ohio only), labeled as a routine review with no change to coverage guidelines. The billing team should confirm the policy's current coverage criteria for Ohio Medicaid members, since the notice gives no detail on specific codes or requirements.
UnitedHealthcare · Effective Dec 1, 2026Low impact
Rituximab (Riabni® , Rituxan ® , Ruxience® , & Truxima ® ) (for Ohio Only)
UnitedHealthcare Community Plan of Ohio published a November 2026 medical policy update for its Rituximab policy (Riabni, Rituxan, Ruxience, and Truxima) covering Ohio Medicaid members. The update is a routine review, and the bulletin states no change to coverage guidelines. Billing teams should note the revised policy text but no new billing or documentation steps appear in the source.
UnitedHealthcare · Effective Dec 1, 2026Low impact
Nplate ® (Romiplostim) (for Ohio Only)
UnitedHealthcare Community Plan of Ohio published its November 2026 Medicaid medical policy update bulletin, which includes a routine review of the Nplate (romiplostim) policy for Ohio members. The bulletin states no change to coverage guidelines. Billing teams treating Ohio Medicaid members who receive Nplate should keep current coverage criteria on file and confirm the policy's effective date of 2026-12-01 in their own workflows.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease (for Ohio Only)
Effective 2026-12-01, the Ohio Medicaid medical policy for amyloid-directed monoclonal antibodies for Alzheimer's disease now states that it applies to Leqembi (lecanemab-irmb) given by intravenous infusion by a healthcare professional. Leqembi IQLIK, the self-administered subcutaneous injection, is obtained under the pharmacy benefit unless the member-specific benefit plan document says otherwise.
UnitedHealthcare · Effective Dec 1, 2026Low impact
Gamifant® (Emapalumab-Lzsg) (for Ohio Only)
UnitedHealthcare Community Plan of Ohio updated its Medical Benefit Drug Policy for Gamifant (emapalumab-lzsg) in the November 2026 medical policy update bulletin, refreshing the clinical evidence and references sections. The published update lists a Medicaid effective date of 2026-12-01 for Ohio members.
UnitedHealthcare · Effective Dec 1, 2026Low impact
Brineura ® (Cerliponase Alfa) (for Ohio Only)
UnitedHealthcare Community Plan of Ohio published its November 2026 medical policy update bulletin, including an updated Medical Benefit Drug Policy for Brineura (cerliponase alfa) effective 2026-12-01. The update is described as a routine review with no change to coverage guidelines, so billing teams serving Ohio Medicaid members should keep existing Brineura claim workflows in place and confirm the policy text against their current payer documentation.
UnitedHealthcare · Effective Dec 1, 2026Low impact
Botulinum Toxins A and B (for Ohio Only)
UnitedHealthcare Community Plan of Ohio updated its Botulinum Toxins A and B medical benefit drug policy in its November 2026 medical policy bulletin, with a stated effective date of 2026-12-01. The update is described as a routine review with no change to coverage guidelines, so the billing team should confirm current requirements for these drugs for Ohio Medicaid members and keep existing documentation and authorization workflows in place.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Video Electroencephalographic (vEEG) Monitoring and Recording (for Ohio Only)
UnitedHealthcare Community Plan of Ohio retired its medical policy on video electroencephalographic (vEEG) monitoring and recording in its November 2026 update bulletin, so these services no longer require clinical review under that policy for Ohio Medicaid members. The retirement takes effect 2026-12-01.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Surgery of the Elbow (for Ohio Only)
UnitedHealthcare Community Plan of Ohio retired its Surgery of the Elbow medical policy for Medicaid members in Ohio, so surgery of the elbow no longer requires clinical review under that policy. Billing teams should stop routing elbow surgery requests for Ohio Community Plan members through the prior review process that this policy previously governed.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Outpatient Surgical Procedures – Site of Service (for Ohio Only)
UnitedHealthcare Community Plan of Ohio updated its Outpatient Surgical Procedures – Site of Service medical policy for Ohio Medicaid members, effective 2026-12-01. Changes add a related-policy reference to the Surgery of the Wrist or Thumb policy, expand the Medical Records Documentation section to state that documentation must fully support medical necessity, be legible, kept in the patient's record and available on request, and update the definition of Poorly Controlled Hypertension and the References section.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Lower Extremity Prosthetics (for Ohio Only)
UnitedHealthcare Community Plan of Ohio added HCPCS code L5992 to its Lower Extremity Prosthetics medical policy for Ohio Medicaid members, and updated the Clinical Evidence and References sections. The change takes effect December 1, 2026.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Hearing Aids and Devices Including Wearable, Bone-Anchored, and Semi- Implantable (for Ohio Only)
UnitedHealthcare Community Plan of Ohio revised its Medicaid medical policy for hearing aids and devices, effective 2026-12-01. The revision adds coverage language stating that a semi-implantable electromagnetic hearing aid for sensorineural hearing loss is proven and medically necessary for individuals who are not candidates for an air conduction hearing aid when used per FDA labeled indications, and it removes the InterQual CP: Procedures, Hearing Device, Middle Ear reference while updating the description, evidence and references sections.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications (for Ohio Only)
UnitedHealthcare Community Plan of Ohio updated its Medicaid medical policy for extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue indications, with the updated policy effective 2026-12-01. The revision refreshes the clinical evidence and references sections, so billing teams should review the updated criteria before submitting ESWT claims for Ohio Community Plan members.
UnitedHealthcare · Effective Nov 1, 2026Low impact
Virtual Upper Gastrointestinal Endoscopy (for North Carolina Only)
UnitedHealthcare Community Plan of North Carolina retired its Medical Policy for Virtual Upper Gastrointestinal Endoscopy, effective 2026-11-01, so this service no longer requires clinical review under that policy. The billing team should confirm that claims for virtual upper GI endoscopy for North Carolina Community Plan members are no longer routed for policy-based review and that charge entry reflects the change.

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Obstructive and Central Sleep Apnea Treatment (for Tennessee Only)

Glaucoma Surgical Treatments (for Tennessee Only)

Genetic Testing for Neurological Disorders (for Tennessee Only)

Saphnelo® (Anifrolumab-Fnia)

Pasatru™ (Garetosmab-Grts)

Genglycos ™ (Pariglasgene Brecaparvovec-Opnr)

FcRn Blockers

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

Surgery of the Elbow (for Pennsylvania Only)

Cardiovascular Disease Risk Tests (for Pennsylvania Only)

Breast Imaging for Screening and Diagnosing Cancer (for Pennsylvania Only)

White Blood Cell Colony Stimulating Factors (for Ohio Only)

Rituximab (Riabni® , Rituxan ® , Ruxience® , & Truxima ® ) (for Ohio Only)

Nplate ® (Romiplostim) (for Ohio Only)

Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease (for Ohio Only)

Gamifant® (Emapalumab-Lzsg) (for Ohio Only)

Brineura ® (Cerliponase Alfa) (for Ohio Only)

Botulinum Toxins A and B (for Ohio Only)

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

Surgery of the Elbow (for Ohio Only)

Outpatient Surgical Procedures – Site of Service (for Ohio Only)

Lower Extremity Prosthetics (for Ohio Only)

Hearing Aids and Devices Including Wearable, Bone-Anchored, and Semi- Implantable (for Ohio Only)

Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications (for Ohio Only)

Virtual Upper Gastrointestinal Endoscopy (for North Carolina Only)