Alaska providers face a continuous stream of payer policy changes: coverage edits, prior authorization expansions, billing code revisions, and Medicaid reimbursement updates that affect day-to-day practice operations. This page surfaces every tracked policy change that explicitly names Alaska, so your billing and compliance teams can act before the effective date, not after a claim denial.
The September 23, 2026 pharmacy notice announces an updated PDL available on or after October 1 and effective on or after November 1. It adds clinical criteria for Baxfendy and Waskyra and updates existing criteria for IL-5 inhibitors, Palynziq and Wakix. Separately, the interim list updated September 18 adds 44 new-to-market entries requiring prior authorization and/or step therapy; semaglutide and tirzepatide interim criteria are also updated.
Alaska Medicaid clarifies that drug screening services are an included component of comprehensive substance use disorder (SUD) treatment and cannot be billed separately. Providers must not submit separate claims for presumptive or definitive drug screenings when performed on the same date of service as SUD treatment; such claims will be denied or recouped. Independent laboratory providers may only bill separately when drug screening is performed independent of a comprehensive SUD service.
This is a comprehensive Medicare Advantage coverage policy for molecular biomarker tests used in prostate cancer risk stratification (effective 10/1/2026). The policy establishes coverage criteria for tests like ArteraAI, EpiSwitch, IsoPSA, MyProstateScore 2.0, ProMark, and ProsTAV, with coverage determinations based on MAC-specific LCDs/LCAs that vary by geographic jurisdiction. Billing teams must identify the correct MAC jurisdiction and apply the corresponding LCD requirements for each test ordered.
This is a comprehensive Medicare Advantage bariatric surgery coverage policy (HUM-1020-005) effective October 1, 2026, that outlines coverage determinations, limitations, and coding requirements for various bariatric procedures. The policy applies Humana's Medicare Advantage coverage standards and references applicable MAC Local Coverage Determinations by geographic jurisdiction, with specific rules varying by state and MAC region.
This is a revised Medicare Advantage medical coverage policy for spinal fusion surgery (effective 09/01/2026) that consolidates coverage determination, limitations, coding information, and evidence summaries for cervical, lumbar, and thoracic spinal fusion procedures. The policy references multiple MAC-specific Local Coverage Determinations (LCDs) across geographic jurisdictions and outlines covered procedures including traditional fusion, minimally invasive approaches (DLIF, XLIF, MITLIF), sacroiliac joint fusion, and interlaminar fusion techniques. Billing teams must align claims submission with the applicable MAC LCD based on patient location and ensure procedures meet specific medical necessity criteria outlined in the referenced determinations.
This is a comprehensive Medicare Advantage coverage policy for Benign Prostatic Hyperplasia treatments effective September 1, 2026. The policy outlines coverage determinations for multiple BPH treatment modalities including surgical procedures (TURP, prostatectomy, laser therapies), temporary implanted devices, stents, and diagnostic testing. The policy references multiple MAC-specific Local Coverage Determinations (LCDs) that vary by geographic jurisdiction, requiring billing teams to verify applicable coverage rules based on patient location.
Humana Medicare Advantage has revised its Ambulatory Cardiac Monitoring Devices policy effective September 1, 2026. The policy provides updated coverage guidance for various cardiac monitoring technologies (Holter monitors, patch recorders, external loop monitors, implantable loop recorders, and mobile cardiac outpatient telemetry) with MAC-specific coverage determinations by geographic jurisdiction. The policy document appears incomplete but establishes that medical necessity determinations will follow applicable NCDs and LCDs based on the member's jurisdiction.
This is a comprehensive Medicare Advantage coverage policy for neuroablative techniques used to treat chronic pain, effective 08/06/2026. The policy defines coverage criteria, eligible procedures (including radiofrequency ablation, cryoablation, chemical neurolysis, and specialized devices like Intracept), and references MAC-specific LCDs and billing codes by geographic jurisdiction. Billing teams must verify applicable MAC guidelines for their state and ensure claims comply with local coverage determinations.
This is a comprehensive Medicare Advantage policy on neuroablative techniques for chronic pain management, effective 08/06/2026. The policy defines covered denervation procedures (radiofrequency ablation, cryoablation, facet denervation, basivertebral nerve ablation, and others) and references MAC-specific LCDs and NCDs that vary by geographic jurisdiction. Billing teams must verify applicable MAC requirements for their region before processing claims for these procedures.
This is a comprehensive Medicare Advantage policy on genetic testing for hereditary cancer syndromes, effective August 3, 2026. The policy establishes coverage guidelines for germline genetic testing across multiple cancer types (melanoma, gastric cancer, neuroendocrine tumors, renal cell carcinoma, and others) and references specific MAC-based Local Coverage Determinations (LCDs) that vary by geographic jurisdiction. Billing teams must verify applicable MAC jurisdiction and LCD requirements before processing claims.
Humana Medicare Advantage has revised its breast reconstruction coverage policy (effective 08/03/2026) to clarify medical necessity criteria for reconstruction procedures following mastectomy, trauma, or congenital abnormalities. The policy applies MAC-specific Local Coverage Determinations (LCDs) by geographic jurisdiction and establishes criteria for determining coverage of implant removal, reduction mammaplasty, and related procedures. Billing teams must identify the appropriate MAC jurisdiction for each claim and apply the correct LCD requirements.
Humana Medicare Advantage has updated its Breast Excision and Mastectomy policy (HUM-1254-009) effective 08/03/2026. This revised policy clarifies coverage criteria for breast lesion excisions (CPT 19120, 19125), partial mastectomies (CPT 19301, 19302), and gynecomastia mastectomy (CPT 19300) across multiple MAC jurisdictions. The policy establishes specific medical necessity criteria based on biopsy results, lesion characteristics, and anatomical considerations, and applies jurisdiction-specific Local Coverage Determinations (LCDs) for Medicare Administrative Contractors.
This is a comprehensive Medicare Advantage policy for Benign Prostatic Hyperplasia (BPH) treatments that became effective on August 3, 2026. The policy outlines coverage for multiple surgical and minimally invasive treatment modalities including TURP, laser therapies, temporary implanted devices, and stents, with specific coverage determinations varying by MAC jurisdiction. Billing teams must verify applicable MAC-specific LCDs and NCDs by geographic location before processing BPH treatment claims.
Alaska Medicaid is clarifying coverage criteria for Zepbound (tirzepatide) when prescribed for Obstructive Sleep Apnea (OSA). Claims must be accompanied by documented sleep studies showing an Apnea-Hypopnea Index (AHI) ≥15 events/hour in patients with BMI ≥30 kg/m². Claims submitted without qualifying sleep study documentation will be subject to recoupment. Additionally, Zepbound prescribed for weight management alone remains non-covered per existing Alaska Medicaid policy.
This is a revised Medicare Advantage policy for breast imaging (effective 07/01/2026) that establishes coverage criteria for mammography, digital breast tomosynthesis, breast MRI, and ultrasound. The policy clarifies medical necessity requirements and references applicable Local Coverage Determinations (LCDs) by MAC jurisdiction. Billing teams must verify which MAC jurisdiction applies to their geographic location to determine specific coverage rules.
Effective June 22, 2026, Alaska Medicaid enforces timely filing limits as specified in the Policy Clarification Timely Filing Limits revised May 2026, and providers are directed to review that clarification for the applicable deadlines and submission requirements. Effective July 1, 2026, Alaska Medicaid edits claims to verify that ordering and referring providers are enrolled in Alaska Medicaid, and those edits are informational only and do not affect claims payment. Health Care Services also published updated Oral Enteral Nutrition Coverage Criteria guidance that replaces the guidance revised August 21, 2024, streamlining coverage criteria and documentation requirements.
Alaska Medicaid has implemented an automated email enrollment system with four auto-response triggers for provider enrollment submissions. This policy establishes strict formatting requirements for email subject lines, mandatory attachment inclusion, one-submission-per-email rules, and preferred secure submission methods (DocuSign or mail). Billing teams submitting provider enrollment, revalidation, or update requests to Alaska Medicaid must immediately comply with these naming conventions and submission protocols or risk returned submissions and processing delays.
Alaska Medicaid has clarified its timely filing limits, maintaining the 12-month deadline from date of service for claim submissions. The policy outlines specific override situations and required documentation, with adjustment deadlines of either 12 months from service date or 60 days from paid date, and establishes clear appeals timeframes (180 days for first-level, 60 days for second-level).
Alaska Medicaid now requires ALL ordering and referring providers to be enrolled in Alaska Medicaid, even if they don't bill Medicaid directly. Claims may be denied if the ordering provider is not actively enrolled when services are submitted.
Alaska Medicaid requires service authorization for the listed intravenous immunoglobulin HCPCS codes, and for J3490 billed with NDC 25357-0024-01 (Epoxia), for dates of service on or after May 11, 2026. Dental code D9248 is no longer covered for dates of service on or after January 1, 2026, and D9244 and D9245 have been turned on as replacements. The next self-audit cycle for Medicaid providers, covering calendar year 2023 or 2024, is due no later than December 31, 2026.
Effective February 1, 2026, Alaska Medicaid requires 340B dispensing pharmacies to use submission clarification code 20 when billing for 340B drugs and bill no more than actual acquisition cost plus dispensing fee. This ensures proper exclusion from Medicaid drug rebate invoicing to prevent duplicate discounts.
Beginning July 1, 2025, Alaska Medicaid will require prior authorization through HMS Gainwell for behavioral health and substance use disorder residential services that exceed fiscal year limits (ranging from 7 to 180 days depending on service type). Providers must submit service authorization requests demonstrating medical necessity for continued treatment beyond these limits.
Premera's November 2026 Medical Policy and Coding Updates notice lists new, revised, deleted and renumbered medical policies, pharmacy policies and coding changes, with dates from November 1, 2026 through February 5, 2027. Several coding updates list codes that now require review for medical necessity and prior authorization, or are now considered investigational or non-covered. The notice also describes Carelon radiation oncology and genetic testing guideline updates effective November 15, 2026.
Alaska Medicaid has reorganized provider support contacts and issued updated guidance on secondary claim submissions, telehealth coding crosswalks for dual-insurance scenarios, dental authorization formatting, and TPL/TRICARE claim requirements. The Provider Enrollment manager position has been eliminated; providers must now contact the call center at (800) 770-5650 or (907) 644-6800 for enrollment issues, with different contact methods for claims, training, and other support needs.
Alaska Medicaid clarifies Third Party Liability (TPL) billing procedures for providers ineligible for Medicare enrollment, particularly behavioral health providers. Providers unable to enroll in Medicare must now submit proof of ineligibility with claims using attachment code 'EB' on the 837 form and include the Attachment Cover Sheet. Claims for dual-eligible recipients must bill Medicare first; Medicaid pays as secondary only after Medicare processes the claim and issues an EOB.
Premera's September 2026 medical policy and coding update adds new review requirements for several services on different dates. Negative pressure wound therapy codes 97605, 97606, 97607 and 97608 now require review for medical necessity and prior authorization effective September 4, 2026, and immune checkpoint inhibitors now require review for medical necessity and prior authorization effective September 1, 2026. Endovascular stent grafts for abdominal aortic aneurysms (codes 34717 and 34718) will require medical necessity and prior authorization review effective November 6, 2026, and Carelon's radiation oncology guideline states radiation therapy is considered not medically necessary for select conditions, including osteoarthritis, neovascular age-related macular degeneration and refractory ventricular tachycardia, for dates of service on and after November 15, 2026.
UnitedHealthcare is reminding providers that multigene RNA panel testing for hereditary cancer is considered unproven and will be denied. Only DNA-only hereditary cancer panels and single-gene RNA testing remain covered under applicable medical policy and prior authorization requirements.
Premera's August 2026 medical policy and coding update changes coverage review for many services, with effective dates running from August 1 through November 15, 2026. Upper gastrointestinal endoscopy in adults, negative pressure wound therapy, and endovascular stent grafts for abdominal aortic aneurysms now carry added site-of-service, medical necessity or prior authorization review requirements. Carelon guidelines for radiology, sleep disorder management and genetic testing took effect for dates of service on and after September 19, 2026, and the radiation oncology and genetic testing guidelines take effect November 15, 2026.
Alaska Medicaid has updated their professional claims submission process through the Health Enterprise portal. Providers must use the online portal at medicaidalaska.com for claims submission, with new features including pre-submission auditing, claim templates, and specific attachment handling requirements.
Premera's November 2024 medical policy and coding update changes medical necessity criteria for several drugs and services, including Dupixent, Xolair, trastuzumab and rituximab products, and GnRH analogs. It also adds coding updates that require review for medical necessity and prior authorization, including knee arthroplasty codes 27440, 27442, 27443 and 27445, amyloid antibody code J0175, and codes for biofeedback, endometrial ablation, home apnea monitoring and posterior tibial nerve stimulators.
Premera's December 2024 medical policy and coding update adds medical necessity criteria for lymphedema and lipedema surgery, a new shoulder arthroplasty policy, and new or revised criteria for drugs including Ocrevus Zunovo, Dupixent, Ebglyss, Leqselvi and Wegovy. It also lists coding updates that require review for medical necessity and prior authorization, including cervical spine surgery codes 63001, 63015, 63040, 63050, 63051, 63075, 63081 and 63265, and it places infusion drugs such as Tyruko and Alyglo under site-of-service review.
Premera's January 2025 update adds Carelon imaging, genetic testing and radiation oncology guideline changes for dates of service on and after April 20, 2025, and adds new Insulin Therapy and SGLT2 Inhibitors pharmacy policies effective January 1, 2025. It also adds Kisunla to the amyloid antibody policy and lists coding updates that now require review for medical necessity and prior authorization, including amyloid antibody code J0175, folate antimetabolite code J9292, and sickle cell disease code J3392.
Premera's February 2025 update adds carpal tunnel release as a new surgical policy effective May 6, 2025, and changes IL-5 inhibitor and Dupixent asthma criteria, including the blood eosinophil count, which was lowered from 300 to 150 cells/mcL. It also moves Briumvi, Lemtrada, Ocrevus, Ocrevus Zunovo, Tyruko and Tysabri from the multiple sclerosis policy into a new Gene Therapies for Rare Diseases policy effective February 1, 2025, and removes site-of-service review from many infusion and biologic codes while keeping medical necessity and prior authorization review.
Premera's March 2025 update changes adalimumab and pegfilgrastim preferences, with Humira (AbbVie) moving from a preferred to a non-preferred adalimumab product effective July 1, 2025. It also adds new Parkinson's disease and seizure drug policies effective March 1, 2025, and lists code 92972 as now requiring review for investigational, while several SARS-CoV-2 serology codes and code 25448 no longer require review.
Physical and occupational therapy services for individual plans require prior authorization starting with the seventh visit, effective July 3, 2025. Humira (adalimumab) with NDCs starting with 00074 changed from a preferred to a non-preferred adalimumab product, effective July 1, 2025. Several codes now require medical necessity review or prior authorization, and Carelon genetic testing uses the sample or collection date as the date of service for dates of service on and after August 1, 2025.
Physical and occupational therapy services for individual plans require prior authorization starting with the seventh visit, effective July 3, 2025. Carpal tunnel release surgery is considered medically necessary for individuals with carpal tunnel syndrome who have failed conservative therapy when criteria are met, effective May 6, 2025. Tyenne (tocilizumab-aazg) IV was added to site of service review, and Bispecific Antibodies became a new pharmacy policy with Rybrevant, Columvi, Epkinly, Lunsumio, Blincyto, Elrexfio, Imdelltra, Talvey and Tecvayli moved into it, effective May 1 and July 1, 2025.
Effective September 5, 2025, non-individual plans use InterQual criteria to determine the appropriate level of care for all planned procedures, and prior authorization for all inpatient hospital care continues to be required. Physical and occupational therapy services for individual plans require prior authorization starting with the seventh visit, effective July 3, 2025. Spravato (esketamine) nasal spray initial authorization increased from 6 months to 12 months, and substance use disorder in remission requires complete abstinence for at least three months, effective June 1, 2025.
Effective October 3, 2025, codes for several drugs, including J0491, J0517, J0638, J2182, J2351, J2356, J2357, J3032, J3111, J3241, J9024, J9272, J9332 and J9334, now require review for site of service, in addition to the existing medical necessity and prior authorization review. Physical and occupational therapy services for individual plans require prior authorization starting with the seventh visit, effective July 3, 2025. Effective September 5, 2025, non-individual plans use InterQual criteria to determine the appropriate level of care for all planned procedures.
Effective January 1, 2026, site of service is reviewed for advanced imaging services under Carelon Medical Benefits Management's Site of Care for Advanced Imaging criteria, and hospital outpatient site of care is considered medically necessary when ancillary services are required and not available at freestanding centers in the same geographic area. Effective November 7, 2025, bariatric surgery reoperation for inadequate weight loss is considered medically necessary if the original procedure fails, such as unsuccessful band adjustments, resulting in less than 50% excess weight loss or less than 20% total weight loss. Effective November 7, 2025, select surgical procedures previously reviewed for site of service in the inpatient setting are reviewed for site of service in the ambulatory surgical center setting under policy 11.01.525.
CGS Administrators' LCD L39284 (Prostate Cancer Detection with IsoPSA®), revised in R4 dated 11/05/2026, provides limited coverage for the IsoPSA® blood test for men 50 and older with a confirmed PSA above 4 and up to 25 ng/mL and no relative contraindication to biopsy such as less than a 10-year life expectancy. The source states its annual review made no changes, and the stated effective date of 11/5/2026 is already before the analysis date of 2026-11-06, so these criteria are already in effect and should be checked for current applicability. The practice should align IsoPSA® orders and claims with these indications and the confirmed-PSA requirement.
Humana Medicare Advantage revised its neuroablative techniques for chronic pain policy effective 11/01/2026. The policy update describes coverage criteria, limitations, and coding guidance for multiple denervation procedures (radiofrequency ablation, cryotherapy, facet denervation, basivertebral nerve ablation, and other neuroablative techniques). The practice must verify applicable MAC LCDs by geographic jurisdiction, obtain prior authorization as required, and ensure claims are submitted with correct coding and documentation.
Alaska Medicaid is transitioning medical travel booking from CTM (Current Travel Management) to ITS (new vendor) effective 2026-10-21. CTM will stop all travel bookings on that date; ITS will assume operations with a new phone number (888.244.3592) and updated call center hours. Providers must direct members to the correct vendor based on travel dates and use updated vouchers with ITS contact information.
Alaska Medicaid's fiscal agent, HMS, presented at its October 21, 2026 town hall that ITS (Intelligent Travel Services) went live on October 21, 2026 as the travel logistics vendor, and that after October 21 HMS will not send new travel service authorizations to CTM. CTM will continue to support travel it already booked until its contract ends on November 8, 2026. The town hall also covered third party liability billing, stating that Alaska Medicaid will not pay more than the TPL agreed amount unless the remainder is listed as member responsibility, and that travel vouchers must be complete and original.
Alaska State Medicaid transitioned its travel booking vendor from CTM to ITS effective 2026-10-21. Providers must now route Alaska State Medicaid travel authorizations to ITS (888-244-3592) for bookings on or after that date, while CTM remains active through 2026-11-08 for existing tickets. Providers should update member education, voucher templates, and internal workflows to direct travel requests to the correct vendor based on booking date.
This September 16, 2026 Alaska Medicaid Town Hall FAQ provides procedural guidance on enrollment, travel authorization transitions, claims processing, and behavioral health documentation requirements. Key items include: enrollment email addresses and affiliation processing clarification; transition from CTM to ITS for travel booking effective October 21, 2026; secondary billing suspension processes with specific EOB codes; and behavioral health documentation enhancement recommendations. The document clarifies existing processes rather than announcing new policy changes.
Alaska Medicaid is transitioning travel arrangement booking from CTM to ITS, effective 10/21/2026. CTM stops booking on 10/21/2026 (contract ends 11/08/2026); ITS assumes all bookings with a new phone number (888.244.3592). Travel request processes and prior authorization procedures remain unchanged. Providers must educate members on which vendor to contact based on travel dates and update voucher contact information using provided label templates.
This is a Medicare Advantage policy update (effective 10/01/2026) covering noninvasive tests for hepatic fibrosis, including imaging-based tests (MRE, qMRA) and blood-based biomarker panels (ELF, FIB-4, FibroSure, LiverFASt, NIS4, OWLiver, TruD, HepQuantDuO). The policy establishes coverage determination criteria for these tests across multiple MAC jurisdictions. The document provided is incomplete and does not contain the full coverage determination criteria, medical necessity requirements, or specific billing code guidance needed for implementation.
This is a revised Medicare Advantage policy for low frequency, noncontact, nonthermal ultrasound (MIST Therapy) for wound care, effective October 1, 2026. The policy clarifies medical necessity criteria across multiple MAC jurisdictions, requiring that standard wound care demonstrate no improvement or be contraindicated before this therapy is covered. Billing teams must ensure claims include proper documentation of failed standard care and route requests through applicable regional MACs.
Updated permitted provider types and service authorization requirements on the July 2026 Alaska Medicaid DMEPOS Interim Fee Schedule apply to dates of service on or after September 20, 2026, and HCS will continue to accept service authorization requests and claims submitted under the April 2026 interim fee schedule guidelines for dates of service before that date. The six-month moratorium on DME/POS enrollments has expired and those enrollments can now be processed, while Home Health and Hospice enrollments remain paused until November 12. The same town hall covered claim attachment guidelines, billing manual update comments that were due September 25, and a State Travel Office change in which ITS takes over Medicaid travel booking from CTM, with ITS go-live between October 16 and 21, 2026 and the CTM contract ending November 8, 2026.
Humana Medicare Advantage has updated its policy on molecular diagnostic assays and breath testing for transplant rejection, effective 08/30/2026. This policy establishes coverage criteria and references for gene expression profiling tests, antigen-specific T-cell function assays, breath testing (BMAC/Heartsbreath), and donor-derived cell-free DNA tests used to monitor organ transplant recipients. Billing teams must verify MAC-specific Local Coverage Determinations (LCDs) by geographic jurisdiction, as coverage and coding requirements vary significantly by region.
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