Medical policy updates
This policy update consolidates multiple medical policies effective November 1, 2026, with key changes including: (1) molecular testing codes for pulmonary nodules moving to a separate biomarker policy with no coverage changes; (2) genetic testing for mental health conditions replacing an obsolete test with OptimalRx Plus (not covered for Medicare Advantage, not medically necessary for commercial); (3) shoulder joint replacement requiring prior authorization with revised medical criteria; (4) ProMark Risk Score policy consolidation with no coverage changes; and (5) removal of prior authorization for in-lab sleep studies (CPT 95805, 95808, 95810, 95811) for commercial products effective October 1, 2026. Additionally, Medicare Advantage coverage is now subject to change at Medicare's discretion for LTACH admissions.