Upcoming Policies effective October 5, 2026

By October 5, 2026: Billing team must implement prior authorization requirements for amniotic membrane graft claims based on indication and product type. For ophthalmic uses, verify diagnosis matches covered list (bullous keratopathy, corneal perforation, corneal ulcers, persistent epithelial defects, chemical burn, neurotrophic keratitis, Stevens-Johnson syndrome, limbal stem cell deficiency, pterygium, severe dry eye). For non-ophthalmic diabetic lower-extremity ulcers, require documentation that wound area decreased <20% after 2 weeks standard care. All other amniotic membrane applications must be denied as experimental. For TTF therapy claims, require prior authorization with documentation of: (1) newly diagnosed diffuse glioma (astrocytoma WHO grade 4 IDH-mutant OR supratentorial glioblastoma), (2) prior debulking surgery, (3) concurrent temozolomide use, (4) KPS score ≥60%, and (5) daily device wear ≥18 hours. Update billing system denial rules to automatically reject experimental/investigative amniotic membrane products listed in Section III and IV unless prior authorization is obtained. Communicate policy changes to providers in ophthalmology, wound care, orthopedics, and oncology to ensure proper documentation at point of care. Claims submitted after October 5, 2026 without proper authorization or meeting medical necessity criteria will be denied.