Medical and Clinical Policy Updates - Effective August 1, 2026

By August 1, 2026: Billing team must update Sentara Health Plans authorization rules and coverage criteria in all billing systems for 57 revised/reviewed medical policies across surgical, DME, medical, and behavioral health categories. CRITICAL PRIORITY CHANGES: (1) PSA Testing (G2008) — Update to require 'initial' screening language for age 45+; remove percent free PSA as first-line screening; update follow-up intervals to 6-12 months per NCCN guidelines. (2) Thyroid Testing (G2045) — Implement new cascade approach with TSH as first-line test; add new coverage criteria for follow-up testing (fT4/fT3/TT3) and secondary hypothyroidism monitoring; remove coverage for TBG, TRH, reverse T3, and T3 uptake. (3) Allergen Testing (G2031) — Add new exclusion: specific IgE in-vitro testing performed same-day as skin prick testing does NOT meet coverage. (4) Surgical policies (Breast—Surgical 10, Cervical Fusion—Surgical 117, Embolization—Surgical 235) and DME policies (High Frequency Chest Wall Compression—DME 14, Negative Pressure Wound Vac—DME 241) require prior authorization and coverage criteria updates. All provider-facing documentation, encounter forms, and prior authorization workflows must be revised. Access updated policies at sentarahealthplans.com and pal.sentarahealthplans.com. Claims submitted without compliance to new coverage criteria will be denied. Behavioral health policies (BH 18-36) affecting Medicaid require immediate review by any providers serving Medicaid members.