What insurance policy changes affect ENT (Ear, Nose & Throat) providers?

ENT (Ear, Nose & Throat) providers face policy updates from major payers including prior authorization requirements, billing code changes, reimbursement rate adjustments, and coverage criteria revisions. PolicyChanges.app tracks these updates daily across all major insurers.

How often do insurance policies change for ENT (Ear, Nose & Throat)?

Insurance payers publish policy changes on rolling schedules: some quarterly, some monthly, and some with immediate effect. ENT (Ear, Nose & Throat) practices typically see dozens of relevant changes per year across their contracted payers.

How do I get notified of new ENT (Ear, Nose & Throat) policy changes?

Sign up for a free PolicyChanges.app account and create a saved search filtered to ENT (Ear, Nose & Throat). You will get an email when new policy changes match your specialty filter: daily or weekly, your choice, on every plan.

Which payers post the most policy changes affecting ENT (Ear, Nose & Throat)?

Based on tracked changes, ENT (Ear, Nose & Throat) updates have come from payers including Anthem BCBS, UnitedHealthcare.

PAYER POLICY CHANGES

ENT (Ear, Nose & Throat) Insurance Policy Changes

Keeping up with insurance policy changes that affect ENT (Ear, Nose & Throat) practices is a full-time job. This page aggregates the latest payer updates (prior authorization rule changes, reimbursement adjustments, billing code additions and removals, and coverage policy revisions) across all major insurers. Changes are identified and summarized daily so ENT (Ear, Nose & Throat) providers and their billing teams can act before deadlines pass.

Anthem BCBS · Effective Nov 30, 2026High impact
[New York] Medical Policies and Clinical Utilization Management Guidelines update
Anthem Blue Cross Blue Shield in New York is updating 26 medical policies and clinical utilization management guidelines, effective November 30, 2026. These updates include new policies on gene therapies, cellular immunotherapy, and device treatments, as well as revisions to existing guidelines for procedures including breast surgery, deep brain stimulation, cardiac rehabilitation, and cochlear implants. Some policy changes may result in services previously covered being found not medically necessary, requiring prior authorization review updates.
UnitedHealthcare · Effective Dec 1, 2026High impact
Obstructive and Central Sleep Apnea Treatment (for North Carolina Only)
UnitedHealthcare Community Plan of North Carolina (Medicaid) revised its sleep apnea treatment coverage policy effective December 1, 2026. The key change adds 'radiofrequency ablation of the soft palate and/or tongue base' to the list of unproven and not medically necessary surgical procedures, meaning claims for this procedure will be denied for NC Medicaid members. This policy also clarifies coverage criteria for approved treatments (oral appliances, specific surgeries, and hypoglossal nerve stimulation) and reaffirms that certain other procedures remain non-covered.
UnitedHealthcare · Effective Dec 1, 2026High impact
Treatment of Temporomandibular Joint Disorders (for Nebraska Only)
UnitedHealthcare Community Plan of Nebraska is significantly narrowing coverage for TMJ disorder treatments effective December 1, 2026. The policy now covers ONLY TMJ arthroplasty as a surgical option (removing coverage for arthroscopy, discectomy, and reconstruction), eliminates four CPT codes, and removes the reference to botulinum toxin coverage for TMJ disorders. Billing teams must immediately identify and deny claims for discontinued procedures and update their coverage rules.
UnitedHealthcare · Effective Dec 1, 2026High impact
Treatment of Temporomandibular Joint Disorders (for Indiana Only)
UnitedHealthcare Community Plan of Indiana is removing coverage for four CPT codes (21060, 21247, 29800, 29804) related to temporomandibular joint disorder treatment, effective December 1, 2026. Indiana Medicaid providers must stop billing these codes and identify alternative treatment pathways for affected patients.
UnitedHealthcare · Effective Dec 1, 2026High impact
Obstructive and Central Sleep Apnea Treatment (for Indiana Only)
UnitedHealthcare Community Plan of Indiana revised its sleep apnea treatment policy effective December 1, 2026, adding radiofrequency ablation of soft palate/tongue base to the list of unproven procedures, updating applicable HCPCS codes (including new code L8697), and clarifying coverage criteria for surgical and nonsurgical treatments including orthognathic surgery, UPPP, and hypoglossal nerve stimulation with specific age and clinical parameters.
Blue Cross and Blue Shield of Minnesota · Effective Dec 7, 2026High impact
Upcoming Policies effective December 7, 2026
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.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] National accounts: 2027 standard prior authorization requirements
Anthem Blue Cross and Blue Shield is updating prior authorization (PA) requirements for Ohio-based commercial accounts, effective January 1, 2027. The policy establishes comprehensive PA requirements across inpatient admissions, advanced diagnostic testing, DME/prosthetics, transplants, gene therapies, CAR T-cell treatments, mental health services, and numerous surgical procedures. Billing teams must implement these PA requirements in their workflows and systems before the effective date.
Anthem BCBS · Effective Jan 1, 2027High impact
[Virginia] National accounts: 2027 standard prior authorization requirements
Anthem Blue Cross and Blue Shield's October 2026 notice lists the services that will require prior authorization for national accounts commercial members starting January 1, 2027. The list is broad, covering inpatient admissions (including OB stays beyond the federal minimum length of stay), genetic and diagnostic tests, durable medical equipment, transplant and cell and gene therapies, behavioral health programs, cosmetic and reconstructive surgery, and implanted devices, so scheduling and billing need updates before that date.
Anthem BCBS · Effective Jan 1, 2027High impact
[New York] National accounts: 2027 standard prior authorization requirements
Effective January 1, 2027, Anthem is implementing comprehensive prior authorization requirements for National accounts in New York across inpatient admissions, advanced diagnostic testing, specialized DME/prosthetics, transplants, gene therapy, mental health services, and numerous surgical/outpatient procedures. Billing teams must update systems to require pre-certification for these services before claim submission to avoid denials.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Medical Policies and clinical guidelines updates
Anthem Blue Cross and Blue Shield (Ohio) has updated 12 medical policies and clinical guidelines effective January 1, 2027, including new coverage criteria for gene therapies, cellular immunotherapy, hearing loss treatment, and various diagnostic/surgical procedures. All updated policies require prior authorization. Key changes include reclassification of several procedures from investigational to non-medically necessary status, and transition of multiple policies from Medical Policy to Clinical UM Guideline format.
Anthem BCBS · Effective Jan 1, 2027High impact
[Virginia] National accounts: 2027 standard prior authorization requirements
Anthem Blue Cross and Blue Shield (Virginia) is expanding its prior authorization (PA) requirements effective January 1, 2027, for national accounts. The policy now mandates pre-certification for numerous advanced procedures, diagnostic tests, durable medical equipment, gene therapies, CAR T-cell treatments, transplants, mental health services, and surgical procedures. This represents a comprehensive broadening of PA scope across multiple service categories.
Anthem BCBS · Effective Jan 1, 2027High impact
[Georgia] National accounts: 2027 standard prior authorization requirements
Anthem Blue Cross and Blue Shield is expanding prior authorization (PA) requirements effective January 1, 2027, for Georgia commercial accounts. The policy adds comprehensive PA requirements across multiple service categories including advanced diagnostic testing (genetic testing, liquid biopsy, whole genome sequencing), specialized DME/prosthetics (robotic devices, AAC devices, bone growth stimulation), gene replacement therapies, CAR T-cell immunotherapy treatments, and numerous surgical procedures. Billing teams must update systems to require PA for these newly-covered services to avoid claim denials.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Medical Policies and Clinical Utilization Management Guidelines update
Anthem Blue Cross and Blue Shield (Ohio/MyCare Ohio) is implementing 26 new and revised medical policies and clinical utilization management guidelines effective January 1, 2027. This comprehensive update includes new coverage criteria for gene therapies, cellular immunotherapy, advanced diagnostic testing, and surgical procedures. The policy explicitly warns that some previously covered services may now be found non-medically necessary under the revised guidelines.
Blue Cross & Blue Shield of Mississippi · Effective Jan 1, 2027High impact
Interleukin-5 Antagonist Monoclonal Antibodies
Exdensur (depemokimab-ulaa) is not covered on any BCBSMS Formulary. Cinqair (reslizumab) will no longer be covered effective 01/01/2027, and Fasenra (benralizumab) is medically necessary when the listed criteria are met. Prior authorization is required for these medications, and the length of approval is 12 months.
Anthem BCBS · Effective Nov 15, 2026Medium impact
[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
Carelon Medical Benefits Management has added an exclusion for bilateral hypoglossal nerve stimulators in the treatment of obstructive sleep apnea, effective November 15, 2026. Providers must now obtain prior authorization for any hypoglossal nerve stimulator procedures and ensure unilateral (single-sided) implants only for Medicaid coverage under HealthKeepers, Inc. and Anthem HealthKeepers Plus in Virginia.
Anthem BCBS · Effective Nov 28, 2026Medium impact
[Ohio] Clinical Criteria updates
Anthem Blue Cross and Blue Shield Ohio has revised 44 clinical criteria policies for medical drug benefits covering specialty pharmaceuticals (oncology agents, immunology drugs, rare disease treatments, and biologic therapies) effective November 28, 2026. One new criterion (CC-0302 Avlayah) has been added. These revisions update medical necessity requirements and coding edits but do not specify authorization requirement changes—those will be communicated separately. This affects Medicare Advantage and MyCare Ohio members only.
Anthem BCBS · Effective Nov 30, 2026Medium impact
[Virginia] Medical Policies and Clinical Utilization Management Guidelines update
HealthKeepers, Inc. (Anthem) is updating 26 medical policies and clinical utilization management guidelines for Virginia Medicaid members effective November 30, 2026. Changes include new policies for gene therapies, cellular immunotherapy, and cancer treatments, plus revisions to existing guidelines for procedures including breast surgery, deep brain stimulation, and various surgical/rehabilitation services. Some policy changes may result in services previously covered being classified as not medically necessary.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Treatment of Temporomandibular Joint Disorders (for Tennessee Only)
UnitedHealthcare Community Plan of Tennessee revised its Treatment of Temporomandibular Joint Disorders medical policy for Tennessee Medicaid members, effective 2026-12-01. TMJ surgical services (arthroscopy, discectomy, reconstruction) are now assessed against the InterQual CP Arthroplasty TMJ criteria instead of the prior InterQual procedures reference, and CPT 21060, 21247, 29800 and 29804 were removed from the applicable codes list. Multiple occlusal splints, jaw mobility stretching devices and epigenetic appliances remain listed as not medically necessary.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Obstructive and Central Sleep Apnea Treatment (for Tennessee Only)
UnitedHealthcare Community Plan of Tennessee revised its Medicaid medical policy on obstructive and central sleep apnea treatment, effective 2026-12-01. Revised coverage adds radiofrequency ablation of the soft palate and/or tongue base to the list of unproven and not medically necessary surgical procedures, and adds HCPCS code L8697 to the applicable codes list. Removable oral appliances require documentation that PAP therapy failed or was not tolerated, and the policy defines the diagnosis requirements before treatment begins.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Hearing Aids and Devices Including Wearable, Bone-Anchored, and Semi- Implantable (for Ohio Only)
UnitedHealthcare Community Plan of Ohio revised its Medicaid medical policy for hearing aids and devices, effective 2026-12-01. The revision adds coverage language stating that a semi-implantable electromagnetic hearing aid for sensorineural hearing loss is proven and medically necessary for individuals who are not candidates for an air conduction hearing aid when used per FDA labeled indications, and it removes the InterQual CP: Procedures, Hearing Device, Middle Ear reference while updating the description, evidence and references sections.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Obstructive and Central Sleep Apnea Treatment (for Idaho Only)
Effective 2026-12-01, the Idaho Medicaid (UnitedHealthcare Community Plan of Idaho) medical policy for obstructive and central sleep apnea treatment was revised. Radiofrequency ablation of the soft palate and/or tongue base was added to the list of procedures treated as unproven and not medically necessary for OSA, and implantable phrenic nerve stimulation devices (e.g., remedē) for central sleep apnea are listed as unproven and not medically necessary. Hypoglossal nerve stimulation and surgical criteria (AHI thresholds, PAP failure, Epworth score, and drug-induced sleep endoscopy requirements) are restated in the policy.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Outpatient Surgical Procedures – Site of Service
UnitedHealthcare is removing a long list of CPT codes from the applicable-code list of its Outpatient Surgical Procedures site-of-service policy for Exchange plans, and it is also removing the link to the Manipulation Under Anesthesia policy. The change takes effect December 1, 2026. The source does not state a new billing requirement for the removed codes.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Outpatient Surgical Procedures – Site of Service
Effective December 1, 2026, UMR removes more than 500 CPT codes from its Outpatient Surgical Procedures - Site of Service medical policy for commercial plans, and it drops a reference link to the Manipulation Under Anesthesia policy. For those codes, UMR's site-of-service policy no longer applies, so the practice should update its internal UMR site-of-service and prior authorization lists before that date.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Outpatient Surgical Procedures – Site of Service
Effective December 1, 2026, UnitedHealthcare removes more than 500 CPT codes from its Outpatient Surgical Procedures - Site of Service medical policy for commercial plans, and it drops a reference link to the Manipulation Under Anesthesia policy. For those codes, the site-of-service policy no longer applies under this UnitedHealthcare commercial policy, so the practice should update its internal site-of-service and prior authorization lists before that date.
BCBS Tennessee · Effective Dec 1, 2026Medium impact
Tezepelumab-ekko (Tezspire®)
Effective December 1, 2026, BlueCross BlueShield of Tennessee's tezepelumab-ekko (Tezspire) medical policy sets coverage criteria for severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) in members 12 years of age and older. Authorization of 6 months may be granted for severe asthma and for CRSwNP when the listed criteria are met, and authorization of 12 months may be granted for continuation when the member shows improvement or a positive clinical response. All other indications are considered experimental/investigational and not medically necessary.
BCBS Tennessee · Effective Dec 1, 2026Medium impact
Omalizumab Products: Omalizumab (Xolair®); Omalizumab-igec (Omlyclo®)
Omalizumab products Xolair and Omlyclo are covered for moderate to severe persistent asthma with a positive skin test or in vitro reactivity to a perennial aeroallergen, chronic rhinosinusitis with nasal polyps in adults with inadequate response to nasal corticosteroids, IgE-mediated food allergy, chronic spontaneous urticaria that remains symptomatic despite H1 antihistamine treatment, immune checkpoint inhibitor-related toxicity, and systemic mastocytosis when the approval criteria are met. All other indications are considered experimental/investigational and not medically necessary. The effective date is 2026-12-01.
BCBS Tennessee · Effective Dec 1, 2026Medium impact
Mepolizumab (Nucala®)
Nucala is covered for add-on maintenance treatment of severe asthma with an eosinophilic phenotype, chronic rhinosinusitis with nasal polyps in adults, inadequately controlled COPD with an eosinophilic phenotype, eosinophilic granulomatosis with polyangiitis, and hypereosinophilic syndrome when the approval criteria are met. Coverage is not provided for HES secondary to a non-hematologic cause or for FIP1L1-PDGFRA kinase-positive HES. All other indications are considered experimental/investigational and not medically necessary. The effective date is 2026-12-01.
Regence BlueShield · Effective Dec 1, 2026Medium impact
Rhinoplasty
This is a NEW medical policy (effective December 1, 2026) establishing coverage criteria for rhinoplasty procedures. Rhinoplasty is covered only for reconstruction of nasal deformities due to congenital anomalies, tumor resection, or nasal airway obstruction meeting strict criteria (imaging, Cottle maneuver, failed conservative management). Purely cosmetic rhinoplasty remains non-covered. Billing teams must prepare to enforce these criteria retroactively starting December 1, 2026.
Aetna · Effective Dec 8, 2026Medium impact
Lunsotogene Parvec-cwha (Otarmeni) (CPB 1103, reviewed 12-2026-08)
Aetna has issued a new Clinical Policy Bulletin (CPB 1103) establishing coverage criteria for Otarmeni (lunsotogene parvec-cwha), a gene therapy for OTOF-related hearing loss in patients ≤17 years old. The policy requires precertification, mandates administration at Aetna Institutes GCIT Network facilities, and specifies strict eligibility criteria including biallelic OTOF variants, profound sensorineural hearing loss ≥90 dB HL, preserved outer hair cell function, and no prior cochlear implants. Billing teams must implement precertification requirements and ensure claims route through designated networks.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Outpatient Surgical Procedures – Site of Service (for North Carolina Only)
UnitedHealthcare Community Plan of North Carolina revised its Outpatient Surgical Procedures – Site of Service medical policy for North Carolina Medicaid members, effective 2027-01-01. Hospital outpatient department surgery is covered under the listed criteria, which now exempt individuals under 21 when federal, state, or contractual requirements call for coverage, and the definition of Poorly Controlled Hypertension was updated. The practice should confirm that planned surgeries at hospital outpatient departments for these members are documented against the revised criteria and the payer's prior authorization list.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Omnibus Codes
UnitedHealthcare's November 2026 commercial medical policy bulletin revises coverage for the Omnibus Codes group, adding several services as unproven and not medically necessary (including digital 3D anatomical models, CRISPR-based TB plasma/serum analysis, multianalyte Alzheimer's/dementia laboratory tests, photobiomodulation for AMD, and CPT 17999 under meibomian gland evaluation) and revising criteria for IRE ablation, BeScreened-CRC, BIOTIA-ID, IVD CAPSULE PSP, histotripsy (now including pancreatic tumors), external urine management systems, Tarlov cyst surgery, and percutaneous gastrostomy with magnetic gastropexy. The billing team should stop scheduling and billing these services for commercial members and update charge entry and claim edits so they are not submitted as covered services, with the effective date of January 1, 2027 stated in the bulletin.
Blue Cross & Blue Shield of Mississippi · Effective Jan 1, 2027Medium impact
Interleukin-5 Antagonist Monoclonal Antibodies - Revised Policy Effective Date: 01/01/2027 [Notice Date: 11/01/2026]
Effective January 1, 2027, the BCBSMS policy for interleukin-5 antagonist monoclonal antibodies adds Cinqair (reslizumab) and Exdensur (depemokimab-ulaa) as not covered on any BCBSMS Formulary. It adds Fasenra (benralizumab) as medically necessary when the listed criteria are met, revises the medically necessary criteria, and changes the length of approval from 6 to 12 months. The code tables add HCPCS J0517 as medically necessary and HCPCS J2361 and J2786 as not medically necessary.
Health Net · Effective Jan 1, 2027Medium impact
26-1201 Updates to Prior Authorization Requirements
Health Net updated its prior authorization lists for California. Preferred and non-preferred status for the denosumab (Prolia, Xgeva and biosimilars) and ustekinumab biosimilars changed effective immediately, and several procedures and equipment codes stopped needing prior authorization for Medicare members effective November 1, 2026 (already in effect). New prior authorization requirements for wound care, scalp cooling and some outpatient drugs start January 1, 2027, and the notice says prior authorization changes do not confirm benefit coverage.
Regence BlueShield · Effective Jan 1, 2027Medium impact
Hypoglossal Nerve Stimulation
Effective January 1, 2027, hypoglossal nerve stimulation using the Inspire device may be considered medically necessary in adults with obstructive sleep apnea when the AHI is at least 15 and no more than 100 with less than 25% central apneas, when PAP has failed or the patient is not an appropriate PAP candidate, when BMI is less than 40 kg/m2, when drug-induced sleep endoscopy shows non-concentric retropalatal obstruction, and when the patient is 22 years of age or older, or is 18 to 22 years of age and has had or is contraindicated for adenotonsillectomy. Adolescents and young adults aged 10 to 21 with Down syndrome may be considered under separate criteria, and revisions to an existing stimulator may be considered medically necessary after placement. Replacement of all or part of a stimulator or generator may be considered medically necessary when it is malfunctioning, cannot be repaired, or is no longer under warranty. Hypoglossal nerve stimulation is not medically necessary when the AHI criterion or the PAP-failure criterion is not met, including PAP refusal, and is investigational when criteria are not met for reasons other than PAP failure or intolerance, when used with other devices such as Genio or the aura6000 system, and for all other indications.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[California] National accounts: 2027 prior authorization requirements
Anthem Blue Cross updates its standard prior authorization requirements for national accounts, effective January 1, 2027. The standard list covers inpatient admissions, diagnostic testing, durable medical equipment, transplant and gene and cell therapies, mental health and substance abuse services, outpatient and surgical procedures, and radiation therapy and radiology services. Gene replacement therapy requires clear confirmation that the group has excluded the benefit, and pre-certification is required if the benefit is covered.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Virginia] Precertification list change notification
Anthem Blue Cross and Blue Shield is adding seven new services to its precertification (prior authorization) requirements effective January 1, 2027. These include durable medical equipment, gene therapy, prosthetic devices, and surgical procedures. Billing teams must obtain precertification for these services before rendering them to avoid claim denials and reimbursement complications.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Georgia] Precertification list change notification
Effective January 1, 2027, Anthem Blue Cross and Blue Shield (Georgia) is adding 7 new services to its precertification requirement list, including DME devices, gene therapy, prosthetics, and surgical procedures. Billing teams must obtain prior authorization for these services before rendering them to avoid reimbursement complications.
Anthem BCBS · Effective Jan 30, 2027Medium impact
[California] Medical Policies and Clinical Utilization Management Guidelines update
Anthem Blue Cross Medi-Cal Managed Care is updating 15 medical policies and 13 clinical utilization management guidelines effective January 30, 2027. Changes include new policies for gene therapy, cellular immunotherapy, and hearing loss treatment; revised policies for breast procedures, deep brain stimulation, and multiple clinical guidelines; and conversion of certain guidelines to new standards. Some revisions may result in services previously covered being found not medically necessary, requiring prior authorization review.
Premera Blue Cross · Effective Nov 1, 2026High impact
Medical Policy and Coding Updates - November 2026
Premera Blue Cross (WA) published its November 2026 medical policy and coding update. Several changes take effect on different dates: Nov 1, Nov 6, Nov 15, Nov 16, 2026, Dec 3, 2026, Jan 1, 2027, and Feb 5, 2027, including new prior authorization/medical necessity review requirements for specific CPT/HCPCS codes (e.g., 33340, 31240, J1818, J9999, 52284, 17313–17315, 30117, 31242, 31243, S3600, S3601, C9762, C9763) and some codes now considered investigational or non-covered. Because the notice mixes past, current and future effective dates, the billing team should confirm applicability per date and per plan before acting.
Regence BlueShield · Effective Nov 1, 2026High impact
Surgical Site of Care – Hospital Outpatient
This policy establishes medical necessity criteria for surgical procedures performed in hospital outpatient departments versus ambulatory surgery centers (ASCs) or physician offices, effective November 1, 2026. The policy applies to a codes list (not provided in this excerpt) and requires prior authorization review for site of care when procedures are performed in an outpatient hospital setting. Billing teams must ensure claims for affected procedures include supporting clinical documentation that meets one or more of the specified medical necessity criteria, or the claim may not meet coverage requirements.
UnitedHealthcare · Effective Nov 1, 2026High impact
Obstructive and Central Sleep Apnea Treatment (for Pennsylvania Only)
UnitedHealthcare Community Plan of Pennsylvania updated its Obstructive and Central Sleep Apnea treatment policy effective November 1, 2026. The revision adds radiofrequency ablation of the soft palate and/or tongue base to the list of unproven and not medically necessary procedures, updates clinical evidence references, and clarifies coverage criteria for surgical and non-surgical treatments. Billing teams must immediately identify and deny claims for this newly excluded procedure.
Anthem BCBS · Effective Nov 1, 2026High impact
[California] Medical Policies and Clinical Utilization Management Guidelines update
Anthem Blue Cross (California) is updating 28 medical policies and clinical utilization management guidelines effective November 1, 2026, including new coverage policies for gene therapies, cellular immunotherapy, and advanced diagnostic/procedural guidelines. The update explicitly warns that some previously covered services may now be found not medically necessary under revised criteria, requiring immediate review of affected service lines.
Anthem BCBS · Effective Nov 1, 2026High impact
[New York] Medical Policies and Clinical Utilization Management Guidelines update
Anthem Blue Cross and Blue Shield has updated 27 medical policies and clinical utilization management guidelines effective November 1, 2026. These changes include new coverage policies for gene therapies, cellular immunotherapy, and emerging treatments, plus revisions to existing policies for common procedures like breast surgery, deep brain stimulation, cardiac rehabilitation, and cochlear implants. Some policy changes may result in previously covered services being determined as not medically necessary.
Anthem BCBS · Effective Nov 1, 2026High impact
[Virginia] Medical Policies and Clinical Utilization Management Guidelines update
Anthem Blue Cross and Blue Shield (Virginia) is updating 27 medical policies and clinical utilization management guidelines effective November 1, 2026. Changes include new policies for gene therapies, cancer treatments, and cellular immunotherapy; revised policies for breast surgery, deep brain stimulation, and multiple clinical guidelines; and conversions of several guidelines to new formats. Some changes may result in previously covered services being classified as not medically necessary, requiring immediate provider review and workflow updates.
Anthem BCBS · Effective Nov 1, 2026High impact
[Georgia] Medical Policies and Clinical Utilization Management Guidelines update
Anthem Blue Cross and Blue Shield (Georgia) is implementing 28 new and revised Medical Policies and Clinical Utilization Management Guidelines effective November 1, 2026. These changes span multiple service categories including gene therapies, surgical procedures, imaging, rehabilitation, and transplantation. Some revisions may result in previously covered services being determined as not medically necessary, requiring immediate review of affected service lines.
UnitedHealthcare · Effective Nov 1, 2026High impact
Obstructive and Central Sleep Apnea Treatment (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky revised its sleep apnea treatment coverage policy, effective November 1, 2026. Key changes include: (1) adding radiofrequency ablation of soft palate/tongue base to the list of unproven/non-covered procedures, (2) clarifying coverage criteria for removable oral appliances and surgical procedures like UPPP and hypoglossal nerve stimulation with specific clinical thresholds, and (3) updating definitions and references. Billing teams must ensure claims for newly classified non-covered procedures are denied appropriately and that covered procedures include required clinical documentation.
UnitedHealthcare · Effective Nov 1, 2026High impact
Obstructive and Central Sleep Apnea Treatment
UnitedHealthcare revised its sleep apnea treatment policy effective November 1, 2026, adding radiofrequency ablation of the soft palate and/or tongue base to the list of unproven and not medically necessary procedures for obstructive sleep apnea. This means claims for radiofrequency ablation procedures will be denied for OSA treatment. The policy also updated clinical evidence sections and clarified coverage for oral appliances, surgical procedures, and hypoglossal nerve stimulation.
UnitedHealthcare · Effective Nov 1, 2026High impact
Rhinoplasty and Other Nasal Procedures
UnitedHealthcare Surest is revising coverage criteria for rhinoplasty and nasal procedures effective November 1, 2026. Three procedures are now classified as unproven and not medically necessary: absorbable polylactic acid nasal cartilage implants (Latera), posterior nasal nerve/sphenopalatine ganglion ablation (RhinAer, ClariFix), and radiofrequency treatment of nasal valves (VivAer). All other nasal valve repairs, primary rhinoplasty, revision rhinoplasty, and tip rhinoplasty now require stringent documentation including physical examination findings, photography, conservative treatment history, and surgeon assessment of valve compromise type and location.
UnitedHealthcare · Effective Nov 1, 2026High impact
Xolair ® (Omalizumab)
UnitedHealthcare revised coverage criteria for Xolair (omalizumab) provider-administered injections across multiple indications (asthma, nasal polyps, food allergy, chronic urticaria). Key changes include removal of IgE level thresholds for asthma, expanded clinical language for nasal polyps and food allergy, addition of new anti-IL-5 therapy contraindications (Exdensur, Nucala), and new H1-antihistamine trial requirements for chronic urticaria. These changes affect coverage determination and prior authorization requirements effective November 1, 2026.
Blue Cross & Blue Shield of Mississippi · Effective Nov 1, 2026High impact
State and School Employees' Health Insurance Plan - Interleukin-5 Antagonist Monoclonal Antibodies
Cinqair (reslizumab), Fasenra (benralizumab) and Nucala (mepolizumab) may be considered medically necessary when the listed criteria are met for severe eosinophilic asthma, eosinophilic granulomatosis with polyangiitis (EGPA) and hypereosinophilic syndrome (HES), and Nucala is also covered for chronic rhinosinusitis with nasal polyps (CRSwNP). As of the 11/01/2026 update, Exdensur (depemokimab-ulaa) is not covered on the State Health Plan Medical Drug Formulary, Fasenra (benralizumab) is medically necessary when the listed criteria are met, and the initial approval length changed from 6 months to 12 months. Requests for Nucala vials or Fasenra syringes that a healthcare professional administers require that the patient tried the corresponding self-administered product unsuccessfully or is clinically unable to use it.

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[New York] Medical Policies and Clinical Utilization Management Guidelines update

Obstructive and Central Sleep Apnea Treatment (for North Carolina Only)

Treatment of Temporomandibular Joint Disorders (for Nebraska Only)

Treatment of Temporomandibular Joint Disorders (for Indiana Only)

Obstructive and Central Sleep Apnea Treatment (for Indiana Only)

Upcoming Policies effective December 7, 2026

[Ohio] National accounts: 2027 standard prior authorization requirements

[Virginia] National accounts: 2027 standard prior authorization requirements

[New York] National accounts: 2027 standard prior authorization requirements

[Ohio] Medical Policies and clinical guidelines updates

[Virginia] National accounts: 2027 standard prior authorization requirements

[Georgia] National accounts: 2027 standard prior authorization requirements

[Ohio] Medical Policies and Clinical Utilization Management Guidelines update

Interleukin-5 Antagonist Monoclonal Antibodies

[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines

[Ohio] Clinical Criteria updates

[Virginia] Medical Policies and Clinical Utilization Management Guidelines update

Treatment of Temporomandibular Joint Disorders (for Tennessee Only)

Obstructive and Central Sleep Apnea Treatment (for Tennessee Only)

Hearing Aids and Devices Including Wearable, Bone-Anchored, and Semi- Implantable (for Ohio Only)

Obstructive and Central Sleep Apnea Treatment (for Idaho Only)

Outpatient Surgical Procedures – Site of Service

Outpatient Surgical Procedures – Site of Service

Outpatient Surgical Procedures – Site of Service

Tezepelumab-ekko (Tezspire®)

Omalizumab Products: Omalizumab (Xolair®); Omalizumab-igec (Omlyclo®)

Mepolizumab (Nucala®)

Rhinoplasty

Lunsotogene Parvec-cwha (Otarmeni) (CPB 1103, reviewed 12-2026-08)

Outpatient Surgical Procedures – Site of Service (for North Carolina Only)

Omnibus Codes

Interleukin-5 Antagonist Monoclonal Antibodies - Revised Policy Effective Date: 01/01/2027 [Notice Date: 11/01/2026]

26-1201 Updates to Prior Authorization Requirements

Hypoglossal Nerve Stimulation

[California] National accounts: 2027 prior authorization requirements

[Virginia] Precertification list change notification

[Georgia] Precertification list change notification

[California] Medical Policies and Clinical Utilization Management Guidelines update

Medical Policy and Coding Updates - November 2026

Surgical Site of Care – Hospital Outpatient

Obstructive and Central Sleep Apnea Treatment (for Pennsylvania Only)

[California] Medical Policies and Clinical Utilization Management Guidelines update

[New York] Medical Policies and Clinical Utilization Management Guidelines update

[Virginia] Medical Policies and Clinical Utilization Management Guidelines update

[Georgia] Medical Policies and Clinical Utilization Management Guidelines update

Obstructive and Central Sleep Apnea Treatment (for Kentucky Only)

Obstructive and Central Sleep Apnea Treatment

Rhinoplasty and Other Nasal Procedures

Xolair ® (Omalizumab)

State and School Employees' Health Insurance Plan - Interleukin-5 Antagonist Monoclonal Antibodies