2025 September Medical Policy Updates

IMMEDIATE ACTION REQUIRED: (1) Billing team and clinical leadership must review CAM 138 hierarchy change immediately and update all prior authorization workflows to prioritize: Contract terms first, then Plan of Benefits, then CAM policies, then MCG criteria. This affects all claim review processes. (2) For amniotic membrane/fluid injections (CAM 701149): Update billing system to recognize and accept new HCPCS codes Q4383, Q4384, Q4386-Q4397 for non-ophthalmic applications, effective immediately. Train coders on proper code assignment. (3) For renal denervation procedures (CAM 701136): This procedure now has POSITIVE coverage for uncontrolled hypertension (previously investigational). Update authorizations to APPROVE claims meeting coverage criteria; remove investigational denials for this indication. Update provider templates and prior auth forms. (4) For orthognathic surgery (CAM 041): STOP billing/approving OSA treatment under this policy; OSA treatment has been moved to CAM 701101. Update diagnosis code restrictions in billing system to reject OSA diagnoses. Failure to implement these changes may result in claim denials or inappropriate approvals. By October 15, 2025: Complete system updates and staff retraining for all four substantive policy changes.