Medicare AdvantagePrior AuthMedium impact
26-061m Updates to Medicare Clinical Policies – December 2025
Health Net·Hematology, Oncology, Plastic Surgery·Prior Authorization
Effective date
Feb 9, 2026
We identified it
Jun 20, 2026
Summary
Centene Medicare updated three clinical policies effective February 9, 2026: relaxed criteria for blood stem cell transplants for sickle cell and thalassemia patients, removed coverage for certain cosmetic procedures that only improve appearance, and created new policies for durable medical equipment and medical necessity criteria.
Action Required
Before February 9, 2026: Billing team must review updated prior authorization criteria for allogeneic hematopoietic cell transplants (AHCT) for sickle cell anemia and β-thalassemia patients - note relaxed stroke risk requirements and removed donor restrictions. Update cosmetic procedure billing to exclude procedures that only improve appearance without functional benefit. Review new durable medical equipment and medical necessity policies on Centene's Medicare Prior Authorization Medical Clinical Policies page.