Medicare AdvantagePrior AuthMedium impact
25-1125m Updates to Medicare Clinical Policies - September 2025
Health Net·CA · Pulmonology, Infectious Disease, Gastroenterology +4 more·Prior Authorization
Effective date
Nov 1, 2025
We identified it
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.
Action Required
By November 1, 2025: Billing 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. Update skin substitute billing to reflect that HCPCS codes A2009 and Q4304 now support medical necessity. Review transplant service documentation requirements to ensure separate authorization for transplant admissions and post-transplant follow-up visits. Contact Provider Services at 800-641-7761 for Medicare-specific questions.