What insurance policy changes affect Kansas providers?

This page tracks changes from major payers (including Medicaid managed care, commercial insurers, and Medicare Advantage plans) that explicitly apply to Kansas. Changes include prior authorization updates, billing code additions or deletions, and reimbursement rate revisions.

How often are Kansas policy changes updated?

Our scrapers run daily and publish new findings within 24 hours of detection. Each change includes an effective date where stated so you can prioritize what requires immediate action.

How do I get alerted to new Kansas insurance policy changes?

Create a free alert on PolicyChanges.app and filter by state to Kansas. You will get an email when new matching changes are detected: daily or weekly, your choice, on every plan.

PAYER POLICY CHANGES

Kansas Insurance & Medicaid Policy Updates

Kansas 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 Kansas, so your billing and compliance teams can act before the effective date, not after a claim denial.

UnitedHealthcare · Effective Dec 1, 2026High impact
Treatment of Temporomandibular Joint Disorders (for Kansas Only)
UnitedHealthcare Community Plan of Kansas (Medicaid) is narrowing TMJ disorder coverage effective December 1, 2026. TMJ arthroplasty remains covered for adults and children, but arthroscopy, discectomy, and reconstruction procedures are no longer covered. Additionally, jaw mobility mechanical stretching devices (e.g., TheraBite, Jaw Dynasplint) are now classified as unproven and not medically necessary. Four CPT codes (21060, 21247, 29800, 29804) have been removed from applicable codes.
Ambetter · Effective Dec 5, 2026High impact
Evolent Musculoskeletal Program Updates Effective 12/05/2026
Effective December 5, 2026, Evolent (on behalf of Sunflower) is implementing new site-of-care selection requirements for shoulder, hip, knee, and spine surgeries. Ordering providers must now select a preferred outpatient or inpatient site during authorization requests; if hospital-based settings are chosen for procedures that can be performed outpatient, providers must justify the selection or select from allowable exceptions. Clinical reviewers will evaluate both medical necessity and site-of-care criteria before authorization.
UnitedHealthcare · Effective Jan 1, 2027High impact
New oncology prior authorization code updates
Effective January 1, 2027, UnitedHealthcare is adding prior authorization requirements for 11 HCPCS oncology medication codes when administered in outpatient settings for cancer treatment. These codes include busulfan, leucovorin calcium, luspatercept, dexrazoxane, dinutuximab, octreotide, triptorelin, omidubicel, zoledronic acid, and cyclosporine. This change applies across commercial, Medicare Advantage, Medicaid, and Individual Exchange plans.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Sunflower Health Plan Billing Code Update for various HCPC H Codes Effective 01/01/2027
Effective January 1, 2027, Ambetter from Sunflower Health Plan will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must identify all claims currently using discontinued codes and establish alternative billing strategies or obtain patient notification protocols before the effective date.
Kansas Medicaid (KanCare) · Effective Jan 1, 2028High impact
KMAP BULLETIN: PPS Rebase for RHCs and FQHCs
KMAP is implementing a Prospective Payment System (PPS) rebase effective January 1, 2028, for Rural Health Clinics (RHCs) and Federal Qualified Health Clinics (FQHCs). All RHC and FQHC facilities in Kansas must submit their 2024, 2025, and 2026 (if available) cost reports by July 1, 2027, to support this rebase calculation.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Vascular Embolization: Select Procedures (for Kansas Only)
UnitedHealthcare Community Plan of Kansas published a new Medicaid medical policy, Vascular Embolization: Select Procedures (for Kansas Only), with an effective date of 2026-12-01. It covers embolization for renal and liver oncology indications and lists arterial embolization for hemorrhoids and several musculoskeletal conditions as unproven and not medically necessary, and it excludes members under 18 and acute/active bleeding indications.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for Kansas Only)
UnitedHealthcare Community Plan of Kansas revised its Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery policy for Kansas Medicaid members aged 19 and older. Stereotactic radiation therapy (SRS and SBRT) is now proven and medically necessary for the listed indications only when medical necessity cannot be determined using the referenced InterQual criteria, and intracranial arteriovenous malformations were added to the list. The extracranial oligometastatic disease criteria were loosened to allow up to five metastatic lesions (previously three), with each lesion 5 cm or smaller and all treated concurrently in a single episode of care.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Medicaid: New policy for select embolization procedures
Effective December 1, 2026, UnitedHealthcare Community Plans in Kansas, Kentucky, and New Jersey will implement a new vascular embolization policy and add prior authorization requirements for CPT code 37242. Services previously evaluated under multiple existing policies will now be consolidated under unified clinical criteria for therapeutic vascular embolization procedures.
Blue Cross Blue Shield of Kansas · Effective Dec 1, 2026Medium impact
Pharmacy Medical Policy Updates
Blue Cross Blue Shield of Kansas (BCBSKS) is updating pharmacy medical policies for 40+ prescription drugs and specialty medications. Updates will be published November 1, 2026, and take effect December 1, 2026. These changes affect prior authorization requirements and coverage criteria for drugs across multiple therapeutic categories including oncology agents, biologics, and specialty pharmaceuticals.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Cardiovascular Disease Risk Tests (for Kansas Only)
UnitedHealthcare Community Plan of Kansas (Medicaid) revised its cardiovascular disease risk testing policy, narrowing the scope of non-covered advanced lipoprotein tests and adding exclusion for noninvasive point-of-care cardiac diagnostic platforms (e.g., CorVista System). One CPT code (1104T) was added and one (83695) was removed from the applicable codes list. This change becomes effective December 1, 2026.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Breast Imaging for Screening and Diagnosing Cancer (for Kansas Only)
UnitedHealthcare Community Plan of Kansas (Medicaid) is revising its breast imaging medical policy effective December 1, 2026, to clarify that certain advanced imaging modalities (Magnetic Resonance Elastography of the Breast, Molecular Breast Imaging, Computed Tomography of the breast, and Computer-Aided Tactile Breast Imaging) remain unproven and not medically necessary for routine screening in normal or high-risk individuals. The policy updates terminology and removes outdated definitions but does not change coverage for conventional mammography.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) (for Kansas Only)
Effective 2027-01-01, UnitedHealthcare Community Plan of Kansas revised its Medicaid medical policy for Whole Exome and Whole Genome Sequencing for non-oncology conditions. The revision adds a cross-reference to the Genetic Testing for Hereditary Cancer policy, removes references to two oncology testing policies, and adds CPT codes 0318U and 0670U through 0677U to the applicable codes list.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for Kansas Only)
UnitedHealthcare Community Plan of Kansas revised its Occipital Nerve Injections and Ablation medical policy for Kansas Medicaid members, adding CPT codes 1057T, 1058T, 1059T, 1060T and 1061T and removing CPT code 64570. The revised policy takes effect January 1, 2027.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Bariatric Surgery (for Kansas Only)
UnitedHealthcare Community Plan of Kansas updated its Bariatric Surgery medical policy for Kansas Medicaid members, effective 2027-01-01. The update removes CPT code 43882 from the applicable codes list and removes the Medical Records Documentation Used for Reviews section, with that information now found at UHCprovider.com/policies under Community Plans > Resources and FAQs.
Blue Cross Blue Shield of Kansas · Effective Jan 1, 2027Medium impact
Important changes to BCBSKS Specialty Pharmacy Network that starts Jan. 1, 2027
Starting Jan. 1, 2027, BCBSKS launches the Advocate+ Pharmacy Match program with Prime Therapeutics, routing new specialty medication starts through Free Market Health (FMH) Pharmacy. Practices continue their standard prior authorization process, e-prescribe the specialty medication to FMH, and then receive a fax assigning the referral to a specialty pharmacy that onboards the member.
Kansas Medicaid (KanCare) · Effective Nov 1, 2026High impact
KMAP BULLETIN: Preferred Drug List Update – November 2026
KMAP (Kansas Medicaid) updates its Preferred Drug List effective November 1, 2026, moving multiple medications between preferred and non-preferred status, adding new agents across multiple therapeutic classes, removing Pancreaze from the PDL, and implementing a Grandfather Prior Authorization process for members on maintenance drugs that newly require PA.
Blue Cross and Blue Shield of Kansas City · Effective Nov 1, 2026High impact
BlueSpeak September 2026: Provider Education
Blue KC is implementing five major policy updates effective November 2026 through January 2027: (1) Post-Payment Clinical Claim Validation reviews with Cotiviti beginning 11/1/26 requiring medical records submission; (2) Maternity billing transition from global codes to encounter-based billing effective 1/1/27, requiring providers to bill E/M codes for individual visits starting 9/1/26; (3) Clarification that concierge services cannot be required for covered services; (4) Flu vaccine awareness guidance for high-risk members; and (5) New NDC requirement for CPT 96379 claims effective 11/1/26.
UnitedHealthcare · Effective Nov 1, 2026High impact
Spinal Fusion and Decompression (for Kansas Only)
UnitedHealthcare Community Plan of Kansas updated spinal fusion and decompression coverage criteria effective November 1, 2026. The policy now requires use of InterQual® Client Defined criteria for lumbar decompression/fusion procedures when standard InterQual® criteria cannot determine medical necessity. Additionally, the policy explicitly lists procedures deemed unproven and not medically necessary (e.g., dynamic stabilization, facet joint replacement, staged procedures for multisite pathology), which will be subject to denial.
Kansas Medicaid (KanCare) · Effective Nov 1, 2026High impact
KMAP BULLETIN: UPDATED: Autism Diagnosis and Diagnosticians Clinical Requirement
Effective November 1, 2026, KMAP requires that autism spectrum disorder (ASD) diagnoses for individuals aged 20 years and younger must be provided by a Kansas BSRB clinical psychologist or a qualified physician with documented ASD training. Diagnoses must include DSM criteria assessment and validated diagnostic tools (ADOS or CARS); cognitive and adaptive behavior evaluations are recommended. Billing teams must verify diagnostician credentials and ensure claims include appropriate provider qualifications before submission.
Kansas Medicaid (KanCare) · Effective Oct 19, 2026High impact
KMAP BULLETIN: Pharmaceutical Prior Authorization Updates – August 2026
Effective October 19, 2026, KMAP adds 30 medications across multiple therapeutic classes to require Clinical Prior Authorization, including oncology agents, immunotherapies, specialty injectables, and oral medications. A Grandfather PA process exempts current maintenance users with ≥80% adherence from the new PA requirement.
Kansas Medicaid (KanCare) · Effective Oct 1, 2026High impact
KMAP BULLETIN: HCPCS Codes Update – October 2026
Effective October 1, 2026, KMAP is adding 34 new HCPCS codes to coverage and discontinuing 12 existing codes. Billing teams must update their systems to recognize the new covered codes and stop billing the discontinued codes to avoid claim denials.
Kansas Medicaid (KanCare) · Effective Oct 1, 2026High impact
KMAP BULLETIN: 2026 Updates to the Medicare Guidelines for Unacceptable Principal Diagnosis Codes
Kansas Medicaid (KMAP) is adopting Medicare's updated list of unacceptable principal diagnosis codes effective October 1, 2026. Billing teams must ensure claims do not submit external causes of morbidity codes, manifestation codes, or other unacceptable codes as principal diagnoses, or claims will be denied. The complete updated code list is available in the Medicare Code Edits v44 document on the CMS website.
Humana · Effective Oct 1, 2026High impact
Molecular Biomarkers for Prostate Cancer Risk Stratification - Medicare Advantage (Revised)
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.
Humana · Effective Oct 1, 2026High impact
Bariatric Surgery - Medicare Advantage (Revised)
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.
Blue Cross and Blue Shield of Kansas City · Effective Oct 1, 2026High impact
BlueSpeak September 2026: Pharmacy Policy Updates
Blue KC is transitioning members to Lumicera Specialty Pharmacy as the exclusive dispensing pharmacy for Fingolimod (0.5mg) and Everolimus (2.5mg, 5mg, 7.5mg, 10mg) effective October 1, 2026. The effective date was moved from September 1, 2026 to allow for smoother provider and member transition. Additionally, a new pharmacy policy for Loargys (pegzilarginase-nbln) for Arginase 1 Deficiency treatment is effective October 1, 2026.
Blue Cross Blue Shield of Kansas · Effective Oct 1, 2026High impact
Pharmacy Medical Policy Updates
Blue Cross Blue Shield Kansas updated pharmacy medical policy for 40+ prescription drugs and biologic agents across two programs (Prescription Drug Policies and Medical Pharmacy Solutions Program Policies). These updates take effect October 1, 2026, with three medications effective November 1, 2026. Billing teams must verify prior authorization requirements and formulary status for all affected medications before the effective date.
Kansas Medicaid (KanCare) · Effective Oct 1, 2026High impact
KMAP BULLETIN: Rate Changes for Physician-Administered Drugs – October 2026
Effective October 1, 2026, KMAP will update Medicaid reimbursement rates for physician-administered drugs (PADs) by aligning pure HCPCS codes with CMS Medicare Part B rates. Unlisted procedure code drugs will continue using WAC-based rates, while High Dollar Rare Disease Drugs follow existing MCO guidelines. LARC product price changes will be retroactive to their effective dates.
Kansas Medicaid (KanCare) · Effective Oct 1, 2026High impact
KMAP BULLETIN: NCCI/MUE Editing – October 2026
Kansas KMAP is implementing quarterly updates to National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUE) rules effective October 1, 2026. Billing teams must review and apply the updated NCCI/MUE editing files from the Medicaid website to ensure accurate claim processing and avoid denials. Implementation timing may vary by KanCare MCO.
Humana · Effective Sep 1, 2026High impact
Spinal Fusion Surgery - Medicare Advantage (Revised)
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.
Humana · Effective Sep 1, 2026High impact
Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)
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 · Effective Sep 1, 2026High impact
Ambulatory Cardiac Monitoring Devices - Medicare Advantage (Revised)
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.
Ambetter · Effective Sep 1, 2026High impact
Comprehensive Payment Integrity: Effective September 1, 2026
Effective September 1, 2026, Sunflower Health Plan will implement prepayment claim reviews using Optum's Comprehensive Payment Integrity tool to identify overutilization and billing irregularities. Providers must now be prepared to submit medical records and billing documentation on demand to support all charges, or face technical denials until documentation is received.
Ambetter · Effective Sep 1, 2026High impact
Malnutrition Policy Revision Policy: Effective September 1, 2026
Sunflower Health Plan is revising its malnutrition policy effective September 1, 2026, to require stricter documentation standards for inpatient claims billing malnutrition as a major complication or comorbidity (MCC). The policy now distinguishes between moderate (non-severe) and severe malnutrition with separate criteria, and adds ICD-10 codes E44.0 and E44.1. Claims billed with malnutrition in non-primary diagnosis positions that lack proper physician documentation will be denied reimbursement.
Ambetter · Effective Sep 1, 2026High impact
Optum Payment Integrity Phase 1: Effective September 1, 2026
Effective September 1, 2026, Sunflower Health Plan (through Optum) will implement prepayment medical record reviews for high-dollar IV hydration therapy and custom fitted/fabricated prosthetics or orthotics across Medicare Advantage, Marketplace, and Commercial plans. Providers must submit requested documentation promptly or claims will be denied; disputes can be filed directly with Optum.
Ambetter · Effective Sep 1, 2026High impact
Optum Payment Integrity - Editing Area: Effective September 1, 2026
Effective September 1, 2026, Sunflower Health Plan (through Optum) is implementing eight new prepayment claim review editing areas targeting specific billing patterns across Medicare, Marketplace, and Commercial plans. Providers will experience increased requests for medical record submission prior to payment; claims without timely documentation submission will be denied. The editing areas focus on trauma activation coding, high-dollar hardware/lab claims, surgical code cross-matching, EEG coding, incision/drainage procedures, and selective catheter placement.
Ambetter · Effective Sep 1, 2026High impact
Optum Payment Integrity - Critical Care Coding: Effective September 1, 2026
Effective September 1, 2026, Sunflower Health Plan (through Optum) will implement prepayment medical record review for critical care coding claims to verify appropriate billing and documentation. Providers will receive increased written requests for medical record submission before payment; failure to return requested documentation will result in claim denials.
Ambetter · Effective Sep 1, 2026High impact
Optum Payment Integrity - Professional Claims for Select Surgical Procedures: Effective September 1, 2026
Effective September 1, 2026, Optum (partnered with Sunflower Health Plan) will implement prepayment medical record review for select surgical procedures on professional claims across Medicare Advantage, Marketplace, and Commercial plans. Billing teams should expect increased written requests for medical record submission prior to payment authorization. Claims without timely documentation submission will be denied, and providers may dispute findings directly with Optum.
Kansas Medicaid (KanCare) · Effective Sep 1, 2026High impact
KMAP BULLETIN: Autism Diagnosis and Diagnosticians Clinical Requirement
Effective September 1, 2026, Kansas Medicaid (KMAP) now requires that autism spectrum disorder diagnoses for individuals aged 20 and younger must be made by a KMAP-approved clinical psychologist or qualified physician (including pediatricians, neurologists, psychiatrists, and family practitioners). Diagnoses must include DSM criteria assessment and validated ASD diagnostic tools (ADOS or CARS). Billing teams must verify provider qualifications and ensure diagnostic documentation meets these requirements before processing claims for ASD-related services.
Blue Cross Blue Shield of Kansas · Effective Sep 1, 2026High impact
Coverage Exception Policy Updates Effective Sept. 1, 2026
Blue Cross Blue Shield of Kansas is updating its Coverage Exception (CE) process effective September 1, 2026. The key change requires members to demonstrate inadequate response to or intolerance of BOTH two generic formulary medications AND two brand-name formulary medications before a non-formulary medication can be approved. Existing approved CEs will continue through their current authorization period, but renewals will use the new criteria.
Blue Cross Blue Shield of Kansas · Effective Sep 1, 2026High impact
Pharmacy Medical Policy Updates
Blue Cross Blue Shield of Kansas is updating pharmacy medical policies for numerous prescription drugs and injectable medications across two implementation timelines: 10 policies effective September 1, 2026, and 2 policies effective August 1, 2026. The Medical Pharmacy Solutions Program is also updating policies for 40+ medications (primarily oncology, ophthalmology, and hematology treatments) effective September 1, 2026. Billing teams must verify prior authorization requirements for affected medications on the insurer's website and update internal systems to reflect new coverage criteria.
Humana · Effective Aug 6, 2026High impact
Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)
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.
Humana · Effective Aug 6, 2026High impact
Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)
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.
Ambetter · Effective Aug 5, 2026High impact
Ambetter Behavioral Health Type of Bill
Ambetter (Sunflower Health Plan in Kansas) has clarified Type of Bill (TOB) requirements for behavioral health claims to reduce denials. Residential Treatment Center services must use TOB 86X, while outpatient behavioral health services must use TOB 13X or 76X. Billing teams must ensure claims are submitted with the correct TOB codes based on the service setting.
Humana · Effective Aug 3, 2026High impact
Percutaneous Coronary Intervention - Medicare Advantage (Revised)
Humana Medicare Advantage updated its Percutaneous Coronary Intervention (PCI) coverage policy effective August 3, 2026, clarifying medical necessity criteria for PCI procedures and adding specific coverage requirements for Coronary Intravascular Lithotripsy (IVL) when treating severely calcified coronary stenosis. The policy applies MAC-specific LCDs across multiple jurisdictions and establishes that PCI is covered for acute coronary syndrome, chest pain despite optimal medical therapy, in-stent restenosis, recent STEMI, and silent ischemia.
Humana · Effective Aug 3, 2026High impact
Genetic Testing for Hereditary Cancer - Medicare Advantage (Revised)
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 · Effective Aug 3, 2026High impact
Cardiac Catheterization and Coronary Angiography - Medicare Advantage (Revised)
Humana Medicare Advantage has updated its cardiac catheterization and coronary angiography coverage policy (Policy HUM-1034-008), effective 08/03/2026. The policy establishes specific medical necessity criteria for coronary/bypass angiography procedures, requiring documented moderate to severe ischemia confirmed by nuclear imaging, echocardiography, cardiac MRI, or exercise testing. Billing teams must verify these criteria are met and documented before submitting claims to avoid denials.
Humana · Effective Aug 3, 2026High impact
Breast Reconstruction - Medicare Advantage (Revised)
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 · Effective Aug 3, 2026High impact
Breast Excision and Mastectomy - Medicare Advantage (Revised)
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.
Humana · Effective Aug 3, 2026High impact
Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)
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.
Kansas Medicaid (KanCare) · Effective Jul 20, 2026High impact
KMAP BULLETIN: Pharmaceutical Prior Authorization Updates – May 2026
Effective July 20, 2026, KMAP (Kansas Medical Assistance Program) now requires Clinical Prior Authorization for 43 newly designated medications, including biologics, specialty pharmaceuticals, and rare disease treatments. Billing teams must implement prior authorization workflows for these drugs before the effective date to prevent claim denials for Kansas Medicaid beneficiaries.

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Treatment of Temporomandibular Joint Disorders (for Kansas Only)

Evolent Musculoskeletal Program Updates Effective 12/05/2026

New oncology prior authorization code updates

Ambetter from Sunflower Health Plan Billing Code Update for various HCPC H Codes Effective 01/01/2027

KMAP BULLETIN: PPS Rebase for RHCs and FQHCs

Vascular Embolization: Select Procedures (for Kansas Only)

Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for Kansas Only)

Medicaid: New policy for select embolization procedures

Pharmacy Medical Policy Updates

Cardiovascular Disease Risk Tests (for Kansas Only)

Breast Imaging for Screening and Diagnosing Cancer (for Kansas Only)

Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) (for Kansas Only)

Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for Kansas Only)

Bariatric Surgery (for Kansas Only)

Important changes to BCBSKS Specialty Pharmacy Network that starts Jan. 1, 2027

KMAP BULLETIN: Preferred Drug List Update – November 2026

BlueSpeak September 2026: Provider Education

Spinal Fusion and Decompression (for Kansas Only)

KMAP BULLETIN: UPDATED: Autism Diagnosis and Diagnosticians Clinical Requirement

KMAP BULLETIN: Pharmaceutical Prior Authorization Updates – August 2026

KMAP BULLETIN: HCPCS Codes Update – October 2026

KMAP BULLETIN: 2026 Updates to the Medicare Guidelines for Unacceptable Principal Diagnosis Codes

Molecular Biomarkers for Prostate Cancer Risk Stratification - Medicare Advantage (Revised)

Bariatric Surgery - Medicare Advantage (Revised)

BlueSpeak September 2026: Pharmacy Policy Updates

Pharmacy Medical Policy Updates

KMAP BULLETIN: Rate Changes for Physician-Administered Drugs – October 2026

KMAP BULLETIN: NCCI/MUE Editing – October 2026

Spinal Fusion Surgery - Medicare Advantage (Revised)

Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)

Ambulatory Cardiac Monitoring Devices - Medicare Advantage (Revised)

Comprehensive Payment Integrity: Effective September 1, 2026

Malnutrition Policy Revision Policy: Effective September 1, 2026

Optum Payment Integrity Phase 1: Effective September 1, 2026

Optum Payment Integrity - Editing Area: Effective September 1, 2026

Optum Payment Integrity - Critical Care Coding: Effective September 1, 2026

Optum Payment Integrity - Professional Claims for Select Surgical Procedures: Effective September 1, 2026

KMAP BULLETIN: Autism Diagnosis and Diagnosticians Clinical Requirement

Coverage Exception Policy Updates Effective Sept. 1, 2026

Pharmacy Medical Policy Updates

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Ambetter Behavioral Health Type of Bill

Percutaneous Coronary Intervention - Medicare Advantage (Revised)

Genetic Testing for Hereditary Cancer - Medicare Advantage (Revised)

Cardiac Catheterization and Coronary Angiography - Medicare Advantage (Revised)

Breast Reconstruction - Medicare Advantage (Revised)

Breast Excision and Mastectomy - Medicare Advantage (Revised)

Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)

KMAP BULLETIN: Pharmaceutical Prior Authorization Updates – May 2026