Summary
Priority Health's May 2026 medical policy updates change coverage criteria across many medical policies. Most changes take effect June 1, 2026, and others take effect August 1, 2026, and both dates are before the analysis date of 2026-11-05, so these changes are historical and their current applicability should be checked before acting. Key changes include prior authorization being required for sacroiliac joint radiofrequency ablation, genicular nerve radiofrequency ablation for knee osteoarthritis, certain skin substitutes, and scar revision, and several procedures moving to not medically necessary.
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What to do
Action · 7 steps
01Already effective June 1, 2026 for most listed policies and August 1, 2026 for others: check current applicability before acting.
02Billing team: obtain prior authorization before billing sacroiliac joint radiofrequency ablation, skin substitutes, genicular nerve radiofrequency ablation for knee osteoarthritis, and scar revision under the Cosmetic and Reconstructive Surgery policy, because prior authorization is required for these.
03Billing team: stop billing continuous passive motion devices for total knee arthroplasty and rotator cuff repair, cooled radiofrequency ablation, nerve cryoablation, and HCPCS A7523 (tracheostomy shower protector), since the source moves them to not medically necessary.
04Billing team: do not bill anesthesia or moderate sedation for interventional pain management unless it is done with a surgical procedure.
05Billing team: for the retired Apnea Monitors and Palliative Care policies, check the billing policy where their content is migrated.
06Billing team: for knee osteoarthritis, TENS, neuroablative therapies, biomechanical shoe-based devices, implanted shock absorbers, synthetic cartilage implants, low-level laser therapy, and prolotherapy are not medically necessary.
07Billing team: for Medicare Advantage members, Special Supplemental Benefits for the Chronically Ill (SSBCI) applies only to Medicare Advantage plans.
Codes mentioned
52284A7523C8002L91.0
Original notice
May medical policy updates
priorityhealth.com · Always check the source before changing claims.