2025 November Medical Policy Updates

Immediately (effective November 2025): (1) Billing team must REMOVE the following CPT/HCPCS codes from all billing systems and encounter forms: 82565, 82575, 84703, 86701, 86702, 86703, 86705, 86803, 86804, 87660, 0500T, G0432, G0433, G0435, G0475, S3645, 87661, 87808, and 87631. (2) ADD new codes 87626, 87800, 87164, and 87166 to billing systems with appropriate policy associations (CAM 209, CAM 210). (3) Update billing software logic for CAM 282 (HIV Testing) to require prior authorization documentation for PrEP coverage and implement new testing frequency limits. (4) Implement new coverage criteria in CAM 161 (Lumbar Spine Procedures): update lumbar fusion revision surgery definition from 6-12 months to 9-12 months following failed operation. (5) Add tobacco/nicotine use contraindication check in billing system for CAM 389 (Lumbar Artificial Disc Replacement). (6) Update CAM 10116 (Negative Pressure Wound Therapy) billing rules: change initial trial period authorization from 14 days to 30 days. (7) For CAM 251 (Minimal Residual Disease), add diffuse large B-cell lymphoma (DLBCL) to coverage criteria. (8) Providers must document updated NCCN guideline alignment for CAM 169 (Lynch Syndrome Testing) and CAM 261 (BRCA genetic testing). (9) Front desk and intake staff must add new documentation checklist for CAM 335 (Alzheimer/dementia biomarkers) including p-tau CSF testing eligibility. (10) Verify all claims submitted with deleted codes will be denied; resubmit with appropriate replacement codes. CONSEQUENCES: Claims using removed codes will be rejected; PrEP claims without proper authorization will be denied; lumbar surgery pre-authorizations submitted with old 6-month criteria will require amendment.