MedicaidCoverageMedium impact
Prostate Artery Embolization - MEDICAID - MICHIGAN (New)
Humana·MI · Urology, Radiology, Vascular Surgery·Medicaid
Effective date
Aug 26, 2026
We identified it
Aug 27, 2026
Summary
Humana Medicaid Michigan has established a new policy effective 08/26/2026 covering Prostate Artery Embolization (PAE) using CPT codes 37242 and 37243 for two indications: hemorrhage, or benign prostatic hyperplasia in patients with prostate size >80g who are not surgical candidates and have no history of prostate or bladder cancer. This is a NEW coverage determination requiring billing teams to implement authorization and documentation protocols.
Action Required
By 08/26/2026: Billing team must (1) Update billing software to recognize CPT 37242 and 37243 as covered services for Michigan Medicaid members; (2) Implement prior authorization requirement—all PAE claims must include documentation of either hemorrhage indication OR benign prostatic hyperplasia with prostate size >80g plus confirmation patient is not a surgical candidate and has no history of prostate or bladder cancer; (3) Add coverage criteria validation to claim submission workflow to prevent denials; (4) Notify providers to include required clinical documentation with PAE authorization requests; (5) For members under age 21, flag requests for medical necessity review per EPSDT requirements. Failure to implement these controls will result in claim denials for non-compliant submissions.