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Upcoming Policies effective December 7, 2026
Effective date
Dec 7, 2026
Identified
Oct 2, 2026
Summary
This policy update revises coverage criteria for Hyperbaric Oxygen Therapy (II-04) and Hematopoietic Stem Cell Transplantation for Acute Lymphoblastic Leukemia (II-118), while inactivating 8 policies including Electroconvulsive Therapy, PET cardiac/oncologic applications, and Wearable Cardioverter Defibrillators. Billing teams must update authorization protocols, stop processing claims under inactivated policies, and verify patient eligibility under the new HSCT and hyperbaric oxygen criteria.
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What to do
Action · 13 steps
01REQUIREMENTS:
By December 7, 2026: Billing team must immediately update prior authorization protocols in the billing system to reflect revised coverage criteria for Hyperbaric Oxygen Therapy (II-04) and HSCT for ALL (II-118).
02Specifically:
1. For Hyperbaric Oxygen Therapy claims: Update authorization rules to require documentation of specific qualifying conditions (e.g., Wagner grade 3+ diabetic wounds with no healing after 30 days of standard therapy, ISSHL with concurrent steroid use within 1 month of onset).
03Flag claims for non-healing diabetic wounds without Wagner grade documentation as requiring additional clinical information before approval.
042. For HSCT (ALL) claims: Update prior authorization workflows to verify risk stratification criteria are met, including MRD positivity status, genetic abnormalities, and prior treatment response for pediatric cases.
05For adult autologous HSCT, confirm absence of suitable allogeneic donor and presence of high-risk factors per policy.
063. Immediately stop processing ANY claims under the 8 inactivated policies (Electroconvulsive Therapy X-46, PET cardiac/oncologic V-31/V-32/V-30, SPECT head V-29, Transcranial Magnetic Stimulation X-14, Wearable Cardioverter Defibrillators II-91, Wheelchairs VII-04).
07Route these claims to denial with notice that coverage under these policies has ended.
084. Providers must document ALL clinical criteria in encounter notes before claim submission.
09Billing team should create a pre-authorization checklist template for these services and distribute to all clinical staff.
105. Contact payer(s) to confirm policy file updates have been received in their systems.
11Verify claim submission guidelines align with this December 7, 2026 effective date.
12Consequences of inaction: Claims submitted without updated criteria documentation will be denied or delayed.
13Claims for inactivated services (e.g., ECT, PET cardiac, wearable defibrillators) will be rejected entirely, creating patient financial liability and reputational risk.
Original notice
Upcoming Policies effective December 7, 2026
bluecrossmn.widen.net · Always check the source before changing claims.