MedicaidCoverageMedium impact
Prostate Artery Embolization - MEDICAID - ILLINOIS (New)
Humana·IL · Urology, Radiology, Vascular Surgery·Medicaid
Effective date
Aug 26, 2026
We identified it
Aug 27, 2026
Summary
Humana Illinois Medicaid has established a NEW coverage policy for Prostate Artery Embolization (PAE) effective 08/26/2026. The procedure is now covered for hemorrhage OR benign prostatic hyperplasia (BPH) when prostate size exceeds 80g, patient is not a surgical candidate, and has no history of prostate or bladder cancer. Billing teams must implement CPT codes 37242 and 37243 with appropriate medical necessity documentation and prior authorization protocols.
Action Required
By August 26, 2026: (1) Billing team must update authorization system to recognize CPT 37242 and 37243 as covered services under Illinois Medicaid when submitted with appropriate clinical justification. (2) Configure system to require prior authorization for both codes with validation of: prostate size >80g documented via imaging, patient not a surgical candidate, and absence of prostate or bladder cancer history. (3) Update encounter forms and provider documentation templates to capture required clinical criteria before claim submission. (4) Communicate policy to urology and interventional radiology providers performing PAE procedures. (5) For patients under age 21, ensure EPSDT medical necessity review is triggered. Claims submitted without meeting coverage criteria (hemorrhage indication OR BPH with required documentation) will be denied.