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Health NetMedicare Advantage · Prior Auth · Prior Authorization · CA · Pulmonology, Infectious Disease, Gastroenterology +4 moreMedium impact

25-1125m Updates to Medicare Clinical Policies - September 2025

Act
by Nov 1, 2025
Effective date
Nov 1, 2025
Identified
Jun 20, 2026

Summary

Centene Medicare has retired three prior authorization policies and updated four existing policies effective November 1, 2025. Key changes include expanded criteria for stem cell therapy, streamlined skin substitute coverage, and clarified transplant documentation requirements.

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What to do

by Nov 1, 2025 · 4 steps
01Billing team must update prior authorization workflows for the three retired policies (respiratory viral panels, home ventilators, GI pathogen testing) - these no longer require separate prior auth.
02Update skin substitute billing to reflect that HCPCS codes A2009 and Q4304 now support medical necessity.
03Review transplant service documentation requirements to ensure separate authorization for transplant admissions and post-transplant follow-up visits.
04Contact Provider Services at 800-641-7761 for Medicare-specific questions.

Codes mentioned

A2009Q4304

Original notice

25-1125m Updates to Medicare Clinical Policies - September 2025
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
View original ↗

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Related policy hubs

Health Net policiesCA policy changesPulmonologyInfectious DiseaseGastroenterologyWound CareHematologyOncologyGeneral SurgeryCode A2009Code Q4304

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