2025 April Medical Policy Updates

IMMEDIATE ACTION REQUIRED - By April 28, 2025: (1) Billing team must update system to DENY all telehealth claims for Physical Therapy, Occupational Therapy, and Speech Therapy (CPT codes 97161-97168, 97169-97171, 92501-92612) under these payer plans; update superbills and encounter forms to block telehealth modifier (-95) for these services. (2) Add CPT code 0573U (Guardant Shield test) to colorectal cancer screening coverage pathway with appropriate medical necessity criteria in billing system. (3) Update surgical treatment for lymphedema/lipedema module: Flag CPT codes 15834, 15835, 18538 as NON-COVERED (cosmetic/not medically necessary) and configure system to auto-deny with notice of non-coverage before billing. (4) Update prior authorization criteria for CAM 701170 (Laser Interstitial Thermal Therapy) to NOW REQUIRE prior auth approval for epilepsy, brain tumors, and radiation necrosis (previously investigational). Add 'Coverage Approval' step to authorization workflow. (5) Billing manager must communicate telehealth denial to all providers and front desk staff immediately. Claims submitted without these updates will be denied. Update payer-specific billing rules in practice management system and communicate changes to all participating providers in SC region.