What insurance policy changes affect Kentucky providers?

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

How often are Kentucky 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 Kentucky insurance policy changes?

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

PAYER POLICY CHANGES

Kentucky Insurance & Medicaid Policy Updates

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

UnitedHealthcare · Effective Dec 1, 2026High impact
Cardiovascular Disease Risk Tests (for Kentucky Only)
UnitedHealthcare Kentucky Medicaid updated its cardiovascular disease risk testing policy effective December 1, 2026, narrowing coverage exclusions for lipoprotein analysis and adding new non-covered technologies including CorVista cardiac diagnostic platforms. CPT code 83695 was removed from the policy, and the policy now references Kentucky state statutes for medical necessity determination. Billing teams must immediately update denial logic and prior authorization workflows to reflect these changes.
UnitedHealthcare · Effective Dec 1, 2026High impact
Breast Imaging for Screening and Diagnosing Cancer (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky (Medicaid) revised its breast imaging policy effective December 1, 2026, clarifying coverage criteria for MRI breast screening in high-risk individuals while designating several advanced imaging modalities (including Molecular Breast Imaging for routine screening and Positron Emission Mammography) as unproven and not medically necessary. The policy removed the standalone BSGI definition and refined language around MRI indications, genetic risk criteria, and age thresholds for screening initiation.
Anthem BCBS · Effective Dec 1, 2026High impact
[New York] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem Medicare Advantage is implementing a new reimbursement policy effective December 1, 2026, that prohibits pass-through laboratory billing (modifier 90) for professional and outpatient facility providers, requiring them to bill directly instead. The existing modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and has been consolidated into this new combined policy.
Anthem BCBS · Effective Dec 1, 2026High impact
[New York] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility
Effective December 1, 2026, Anthem will no longer reimburse outpatient medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 facility claim forms. These services are only reimbursable when submitted by the rendering provider on CMS-1500 professional claim forms using the applicable codes. Participating providers cannot balance bill members for this change.
Anthem BCBS · Effective Dec 1, 2026High impact
[Ohio] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility
Effective December 1, 2026, Anthem will no longer reimburse outpatient medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 facility claims. These services are now eligible for reimbursement ONLY when submitted by the rendering provider on CMS-1500 (professional claim form). Billing teams must route these services to the correct claim form type to avoid denials.
Anthem BCBS · Effective Dec 1, 2026High impact
[Georgia] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility
Effective December 1, 2026, Anthem will no longer reimburse medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 (facility claims). These services are now eligible for reimbursement ONLY when submitted on CMS-1500 (professional claim form) by the rendering provider. Billing teams must immediately audit billing workflows to prevent claim denials and ensure correct claim form submission.
Anthem BCBS · Effective Dec 1, 2026High impact
[Georgia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Effective December 1, 2026, Anthem Medicare Advantage is implementing a new combined reimbursement policy (G-20001) that prohibits reimbursement for laboratory services billed with modifier 90 (pass-through billing). Providers must bill directly for laboratory services and will be reimbursed at 100% of the applicable fee schedule. The existing modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and is consolidated into this new policy. The prior modifier 91 policy (G-06020) is being retired.
Ambetter · Effective Dec 5, 2026High impact
Evolent Musculoskeletal Program Updates: Effective December 5, 2026
Effective December 5, 2026, Ambetter from WellCare of Kentucky (through Evolent) is implementing site-of-care requirements for shoulder, hip, knee, and spine surgeries. Ordering providers must now select a preferred outpatient site when submitting authorization requests for procedures that can be performed in an outpatient setting; hospital-based site selection will require either an allowable exception or clinical justification. Prior authorizations will reflect determinations for both the procedure and site of care.
Ambetter · Effective Dec 6, 2026High impact
Leveling for Facility Claims
Ambetter from WellCare of Kentucky will apply national CPT guidelines to the coding of outpatient emergency department E&M levels for facility claims beginning 12/06/2026. Under the payer's comparative peer risk adjustment process, E&M claim lines will be recoded to the corrected level, with reimbursement at the highest level whose criteria are met, based on facility resources such as nursing time, clinical staff effort, supplies, equipment, and overhead rather than provider cognitive work. The payer's policy CC.PP.80 replaces the previous Optum EDC Analyzer.
UnitedHealthcare · Effective Jan 1, 2027High impact
Denosumab
UnitedHealthcare Community Plan of Kentucky's Medicaid medical policy for denosumab was revised effective 2027-01-01, updating the list of covered denosumab products by adding Boncresa, Jubereq, Osvyrti, Oziltus, and Ponlimsi, with Jubereq and Osvyrti designated preferred and Boncresa, Oziltus, and Ponlimsi designated non-preferred. Coverage for postmenopausal osteoporosis treatment was revised to add an initial-therapy criterion for very high fracture risk (a fracture in the past 12 months or a fracture while on approved osteoporosis therapy), and HCPCS codes Q5166, Q5171, and Q5173 were added. Billing staff should update product and code references and review the new very-high-risk documentation requirements before submitting denosumab claims for these members.
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 WellCare of Kentucky Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from WellCare of Kentucky will discontinue coverage for 46 HCPCS H codes (behavioral health and social services codes), while simultaneously activating coverage for H0006. Billing teams must identify all claims currently using the discontinued codes and establish alternative billing strategies or obtain prior authorization requirements before the effective date.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Omalizumab
UnitedHealthcare's Kentucky Medicaid medical policy for omalizumab was revised to refer to all omalizumab products generically, listing Omlyclo (omalizumab-igec), Xolair, and any FDA-approved and launched biosimilar not named (which is treated as non-preferred until reviewed). HCPCS code Q5154 was added, and the policy clarifies that self-administered subcutaneous omalizumab is obtained under the pharmacy benefit rather than the medical benefit. The revised policy is effective 2026-12-01.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease
UnitedHealthcare Community Plan of Kentucky revised its Medicaid medical benefit policy for Alzheimer's disease amyloid-directed monoclonal antibodies (Kisunla and Leqembi). Continuation-of-therapy criteria now require an Alzheimer's diagnosis and ARIA MRI monitoring per FDA labeling, drop the requirement for submitted follow-up MRI chart notes, and add new criteria for the intravenous Leqembi 10 mg/kg dosing regimens. Leqembi IQLIK subcutaneous self-injection is routed to the pharmacy benefit.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Maximum Dosage and Frequency
UnitedHealthcare Community Plan of Kentucky revised its Maximum Dosage and Frequency medical benefit drug policy, updating the list of maximum allowed quantities and frequencies by HCPCS units and adding Exdensur (depemokimab) and Spinraza (nusinersen). Billing teams should check claims for these drugs against the listed per-administration maximums and dosing frequencies, and confirm that HCPCS codes J2326 and J2361 are added to charge entry and that the revised descriptions for Q5136 and Q5157 are reflected in the charge master.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Ilaris ® (Canakinumab)
UnitedHealthcare Community Plan of Kentucky updated its Ilaris (canakinumab) medical benefit drug policy for Medicaid members in Kentucky, effective 2026-12-01. For Active Still's Disease, including Adult-Onset Still's Disease (AOSD) and Systemic Juvenile Idiopathic Arthritis (SJIA), the coverage rationale now states that the patient must not be receiving Ilaris in combination with another systemic targeted immunomodulator for the same indication.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Vascular Embolization: Select Procedures (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky's new Medicaid medical policy for vascular embolization, effective 2026-12-01, sets coverage limits: renal embolization is covered for preoperative or palliative treatment of renal cell carcinoma and for nonruptured angiomyolipomas at elevated bleeding risk, while arterial embolization for hemorrhoids and musculoskeletal pain (knee, shoulder osteoarthritis, adhesive capsulitis, tendinitis, plantar fasciitis) is deemed unproven and not medically necessary. The policy excludes members under 18 and acute/active bleeding indications, and points to InterQual and NCCN criteria for liver and other oncologic embolization.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Treatment of Temporomandibular Joint Disorders (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky revised its Medicaid medical policy on treatment of temporomandibular joint disorders, effective 2026-12-01. For members 18 and older and under 18, TMJ arthroplasty is now the only surgical service described as proven and medically necessary in certain circumstances, with InterQual criteria cited for each age group. Jaw mobility stretching devices were added to the unproven list, and CPT codes 21060, 21247, 29800, and 29804 were removed from the applicable codes.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for Kentucky Only)
Effective 2026-12-01, UnitedHealthcare Community Plan of Kentucky (Medicaid) revised its stereotactic radiation therapy (SRS and SBRT) policy so that the listed proven-and-medically-necessary indications apply only when medical necessity cannot be determined using the referenced InterQual criteria. The indication list was also revised, adding intracranial arteriovenous malformations, and the policy applies to individuals 19 years of age or older, with SRS and SBRT covered without further review for those younger than 19.
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.
Ambetter · Effective Dec 1, 2026Medium impact
ASAM Criteria Changes for Adolescent and Transition-Aged Youth Substance Use Disorder Services: Effective December 1, 2026
Ambetter from WellCare of Kentucky is implementing ASAM 4th Edition Criteria for adolescent and transition-aged youth (TAY) substance use disorder services effective December 1, 2026. Changes include new admission and continued stay criteria, revised Levels of Care with new youth-specific levels, updated Six Dimensions assessment with a new Person-Centered Considerations dimension, and updated guidance for members aged 18-25. Providers must review and align internal assessments, documentation, and treatment-planning processes before the effective date.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Saphnelo® (Anifrolumab-Fnia)
UnitedHealthcare Community Plan of Kentucky revised its Saphnelo (anifrolumab-fnia) medical benefit drug policy for moderate to severe SLE, adding a criterion that the prescriber attest the patient or caregiver cannot be trained or is physically unable to self-administer Saphnelo or Benlysta (FDA-labeled for self-administration) and submit an explanation, for both initial and continuation requests. Practices should update prior authorization submissions for these infusions to include the attestation and explanation, and confirm the patient meets the Benlysta failure/contraindication/intolerance history before requesting authorization.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
FcRn Blockers
UnitedHealthcare Community Plan of Kentucky revised its FcRn Blockers medical benefit drug policy, effective 2027-01-01, to state that Imaavy is proven and medically necessary for warm autoimmune hemolytic anemia (wAIHA) in adults and children 12 and older currently or previously treated with corticosteroids, subject to specified diagnostic, treatment-history, dosing and prescriber criteria. ICD-10 code D59.11 was added to the applicable codes, and the policy covers Imaavy, Rystiggo, Vyvgart and Vyvgart Hytrulo vial for administration by a healthcare professional.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky revised its Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) medical policy for Kentucky Medicaid members, with the revised policy effective 2027-01-01. Key changes include revised medical necessity criteria (the test must now be ordered by or in consultation with a medical geneticist, neonatologist, neurologist, immunologist, or developmental pediatrician), pretest genetic counseling now recommended rather than strongly recommended, state-specific reference to Kentucky Revised Statutes § 304.17A-263 for biomarker testing criteria, and eleven new CPT codes (0657U, 0658U, 0659U, 0670U–0677U) added to the applicable codes list.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Molecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment Decisions (for Kentucky Only)
Effective 2027-01-01, UnitedHealthcare Community Plan of Kentucky (Medicaid) revised its molecular oncology testing policy for hematologic cancers. Kentucky members' medical necessity is now referred first to Kentucky Revised Statutes § 304.17A-263 biomarker testing criteria, and the policy adds clonoSEQ clonality/MRD coverage, lists specific proven multigene panel and comprehensive genomic profiling uses, and names EpiSwitch Checkpoint Inhibitor Response Test, optical genome mapping and whole-transcriptome sequencing as unproven.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Bariatric Surgery (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky removed CPT code 43882 from its Bariatric Surgery medical policy for Kentucky Medicaid members, as published in the November 2026 medical policy update bulletin. Billing staff should stop using 43882 on claims for these members and confirm the code is removed from charge entry and claim edit lists.
Ambetter · Effective Jan 1, 2027Medium impact
Implementation of Site of Care Optimization Program for Ambetter Health Members
Effective January 1, 2027, Ambetter Health will implement a Site of Care Optimization Program that transitions members receiving infusions in outpatient hospital settings to lower-cost alternatives such as home infusion or ambulatory infusion suites. Providers will be contacted beginning in September 2026 to select preferred sites of care for individual members. The practice should prepare to refer eligible patients to in-network, lower-cost infusion sites and engage with Ambetter's care coordination team for referral and coverage assistance.
Kentucky Medicaid · Effective Jan 1, 2027Medium impact
PDS Transition to Waiver Operating Agency
Kentucky is transitioning oversight of Participant Directed Services (PDS) for 1915(c) waiver programs from the Department for Aging and Independent Living to individual waiver operating agencies. This is a phased transition completing by January 1, 2027, affecting contact information and administrative processes for waiver-related billing.
Anthem BCBS · Effective Feb 1, 2027Medium impact
[New York] Reimbursement policy update: Moderate (Conscious) Sedation — Professional and Facility
Effective February 1, 2027, Anthem will stop separately reimbursing moderate sedation services (revenue codes 0371 and 0372) on inpatient facility claims when reported with room and board charges for Commercial plans in New York and eight other states. Practices must stop billing these codes separately on inpatient UB-04 claims for Anthem members, as payment is now bundled into room and board reimbursement.
Anthem BCBS · Effective Feb 1, 2027Medium impact
[Georgia] Reimbursement policy update: Moderate (Conscious) Sedation — Professional and Facility
Effective February 1, 2027, Anthem will no longer separately reimburse moderate sedation services (revenue codes 0371 and 0372) on inpatient facility claims when reported with room and board charges; reimbursement is now bundled into room and board payment. Billing teams must stop billing these codes separately on inpatient UB-04 claims for Anthem Commercial members in Georgia and other affected states.
UnitedHealthcare · Effective Dec 1, 2026Low impact
Pasatru™ (Garetosmab-Grts)
UnitedHealthcare Community Plan of Kentucky added a medical benefit drug policy for Pasatru (garetosmab-grts) under its Medicaid plan in Kentucky, effective 2026-12-01. Initial therapy requires the patient to be over 18, a fibrodysplasia ossificans progressiva (FOP) diagnosis, supporting chart notes and genetic confirmation of an ACVR1 mutation, prescribing by or with an FOP expert, dosing per FDA labeling, and no combined use with Sohonos (palovarotene), with authorizations up to 12 months; continuation requires documented positive response and the same conditions.
UnitedHealthcare · Effective Dec 1, 2026Low impact
Genglycos ™ (Pariglasgene Brecaparvovec-Opnr)
UnitedHealthcare Community Plan of Kentucky published a Medicaid medical benefit drug policy for Genglycos (pariglasgene brecaparvovec-opnr), a gene therapy for glycogen storage disease type Ia, effective 2026-12-01. Coverage is limited to patients 8 years or older who meet diagnostic confirmation, cornstarch therapy, AAV8 antibody-negative, no prior gene therapy, metabolic specialist involvement, no planned inpatient admission solely for administration, FDA-labeled dosing, and an authorization limit of one lifetime treatment valid for no more than 45 days from approval.
UnitedHealthcare · Effective Nov 1, 2026High impact
FDA Cleared or Approved Companion Diagnostic Testing (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky has revised its companion diagnostic (CDx) testing policy effective November 1, 2026, adding a requirement to first reference Kentucky Revised Statutes § 304.17A-263 for medical necessity determination, then apply the policy criteria if statutory criteria cannot determine necessity. The policy also updated applicable CPT codes to reflect quarterly edits, including addition of CPT 0648U. This affects coverage determinations for FDA-cleared/approved CDx tests used with specific oncology medications across multiple cancer types.
UnitedHealthcare · Effective Nov 1, 2026High impact
Ambulance Services (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky updated its ambulance services policy effective November 1, 2026, adding stricter documentation requirements, referencing Kentucky Administrative Regulations (KAR § 907-001-060) for medical necessity criteria, and introducing HCPCS code A0140. The policy now explicitly requires comprehensive medical record documentation (history, physical exam, diagnostic test results) to support medical necessity claims, and clarifies that documentation does not guarantee coverage.
UnitedHealthcare · Effective Nov 1, 2026High impact
Spinal Fusion and Decompression (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky revised its spinal fusion and decompression medical policy effective November 1, 2026, adding new clinical coverage criteria references to InterQual guidelines, introducing six new clinical definitions, and clarifying that staged/serial procedures for multisite spinal pathology and certain procedures (dynamic stabilization, facet joint replacement, isolated facet joint fusion, vertebral joint implants) are not medically necessary. Billing teams must update their medical necessity determination processes to align with the new InterQual criteria and identify claims that may be subject to denial under the updated non-covered procedures list.
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.
Anthem BCBS · Effective Nov 1, 2026High impact
[Georgia] Reimbursement policy update: Sleep Studies and Related Bundled Services and Supplies — Professional
Effective November 1, 2026, Anthem Blue Cross and Blue Shield is changing how unattended and home sleep studies must be billed. These services must now be billed as professional services on CMS-1500 forms only—they are no longer eligible for reimbursement when billed on UB-04 facility claim forms. Billing teams must ensure sleep study claims are submitted on the correct form type or face denial.
Anthem BCBS · Effective Nov 1, 2026High impact
[New York] Reimbursement policy update: Sleep Studies and Related Bundled Services and Supplies — Professional
Effective November 1, 2026, Anthem is updating its sleep studies reimbursement policy to clarify that unattended and home sleep studies must be billed as professional services on CMS-1500 forms only. These services are NOT eligible for reimbursement when billed on UB-04 facility claim forms. This policy now applies to both professional and facility care providers in multiple states including New York.
Humana · Effective Oct 28, 2026High impact
Bevacizumab products
Humana's pharmacy coverage policy for bevacizumab products (Avastin, Mvasi, Zirabev, Alymsys, Vegzelma, Jobevne) is dated effective 10/28/2026 for Medicare, Medicaid Kentucky, Medicaid South Carolina, and Medicaid Virginia. It sets prior authorization criteria by indication, including a step-therapy requirement that members have an intolerance or contraindication to Mvasi or Zirabev before Avastin, Alymsys, Jobevne, or Vegzelma oncology requests, plus indication-specific diagnosis and regimen requirements. Billing teams should verify these criteria against the current policy version before scheduling affected infusions.
Humana · Effective Oct 28, 2026High impact
Bevacizumab products (New)
Humana has implemented a new Prior Authorization pharmacy coverage policy for bevacizumab products (Avastin, Mvasi, Zirabev, Vegzelma, Alymsys, Jobevne) effective immediately. The policy establishes specific clinical criteria and step-therapy requirements for six oncology indications and three ophthalmology indications across Medicare and three state Medicaid programs (Kentucky, South Carolina, Virginia). Billing staff must verify member eligibility against detailed criteria before processing claims for these drugs.
Humana · Effective Oct 14, 2026High impact
Orthotics - MEDICAID - KENTUCKY (Revised)
Humana Kentucky Medicaid has revised its Orthotics coverage policy, effective 2026-10-14. The policy establishes medical necessity criteria, prior authorization requirements, and specific HCPCS codes for coverage of braces, splints, casts, and other orthotic devices across lower extremity, foot, spine, and upper extremity categories. Billing teams must verify prior authorization is obtained before claims submission and ensure documentation supports medical necessity for each orthotic type.
Humana · Effective Oct 14, 2026High impact
Orthotics - MEDICAID - KENTUCKY (Revised)
Humana Kentucky Medicaid revised its Orthotics policy (HUM-KY-2177-001), effective 2026-10-14. The policy establishes coverage criteria and prior authorization requirements for orthotics including braces, splints, casts, foot orthotics, spine orthotics, and upper extremity orthotics across multiple HCPCS codes. This is a full policy revision with an original effective date of 2025-06-03 and a new effective date of 2026-10-14.
Humana · Effective Oct 14, 2026High impact
Genomic and Molecular Biomarker Testing for Cancer - MEDICAID - KENTUCKY (New)
Humana Kentucky Medicaid has implemented a new coverage policy (HUM-KY-2248-000) for genomic and molecular biomarker testing in cancer patients, effective 10/14/2026. The policy establishes coverage criteria and prior authorization requirements for specific multigene panel tests, single gene tests, liquid biopsies, and other molecular pathology tests used in hematologic malignancies, solid tumors, and thyroid nodule evaluation.
Humana · Effective Oct 7, 2026High impact
Spinal Decompression Surgery - MEDICAID - KENTUCKY (New)
Humana Kentucky Medicaid has issued a new spinal decompression surgery coverage policy (HUM-KY-2660-000) effective 2026-10-07, establishing medical necessity criteria for discectomy, laminectomy, foraminectomy, and related procedures. The policy specifies coverage requirements including diagnostic imaging confirmation, clinical symptoms, and conservative treatment trial periods (6 weeks for herniated disc with radicular pain). Prior authorization is required for all covered services under this policy.
Ambetter · Effective Oct 1, 2026High impact
Update for CPT Codes 80320-80377: Effective 10/1/2026
Effective October 1, 2026, CPT codes 80320-80377 (Definitive Drug Testing Procedures) will no longer be reimbursable. Providers must transition to billing appropriate G-series bundled laboratory codes instead. This is a historical discovery of a policy that became effective on the analysis date.
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.
UnitedHealthcare · Effective Oct 1, 2026High impact
Xolair ® (Omalizumab)
UnitedHealthcare Community Plan of Kentucky revised Xolair (omalizumab) coverage criteria effective October 1, 2026. Key changes include: (1) Added requirement for chronic urticaria patients to trial updosed 2nd generation H1-antihistamines (up to 4-fold) for 2 weeks before Xolair approval; (2) Expanded contraindicated combination therapy list across all indications to include Exdensur (depemokimab) and Nucala (mepolizumab). Billing teams must update prior authorization workflows to enforce new H1-antihistamine trial requirements and screen for drug interactions before claim submission.
UnitedHealthcare · Effective Oct 1, 2026High impact
Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment Decisions (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky (Medicaid) revised its molecular oncology testing policy effective October 1, 2026. Key changes include: (1) clarifying coverage applies only to non-FDA companion diagnostic tests; (2) requiring reference to Kentucky Revised Statutes § 304.17A-263 for medical necessity determination; (3) updating breast cancer Gene Expression Profiling test names (Oncotype DX Breast Recurrence Score®, Prosigna® Breast Cancer Assay); and (4) adding new coverage criteria for blood-based colorectal cancer screening using Shield™ for average-risk individuals aged 45-85 with specific clinical parameters.
Anthem BCBS · Effective Oct 1, 2026High impact
[New York] Reimbursement policy reminder: Provider Preventable Conditions — Professional and Facility
Effective October 1, 2026, Anthem will deny reimbursement for all claims containing a Provider Preventable Condition (PPC) diagnosis code, specifically HAC01 (retention of a foreign object after surgery), including related services. The policy applies to professional and facility claims across multiple states. Providers are prohibited from balance billing members for denied claims under this policy.
Anthem BCBS · Effective Oct 1, 2026High impact
[Ohio] Reimbursement policy reminder: Provider Preventable Conditions — Professional and Facility
Anthem is implementing a Provider Preventable Conditions (PPC) reimbursement policy effective October 1, 2026, that denies reimbursement for claims containing Never Event diagnosis codes, specifically HAC01 (retention of foreign object after surgery). This policy applies to professional and facility claims in Ohio and nine other states. Providers are prohibited from balance billing members for denied claims under this policy.

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Cardiovascular Disease Risk Tests (for Kentucky Only)

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

[New York] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services

[New York] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility

[Ohio] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility

[Georgia] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility

[Georgia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services

Evolent Musculoskeletal Program Updates: Effective December 5, 2026

Leveling for Facility Claims

Denosumab

New oncology prior authorization code updates

Ambetter from WellCare of Kentucky Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Omalizumab

Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease

Maximum Dosage and Frequency

Ilaris ® (Canakinumab)

Vascular Embolization: Select Procedures (for Kentucky Only)

Treatment of Temporomandibular Joint Disorders (for Kentucky Only)

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

Medicaid: New policy for select embolization procedures

ASAM Criteria Changes for Adolescent and Transition-Aged Youth Substance Use Disorder Services: Effective December 1, 2026

Saphnelo® (Anifrolumab-Fnia)

FcRn Blockers

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

Molecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment Decisions (for Kentucky Only)

Bariatric Surgery (for Kentucky Only)

Implementation of Site of Care Optimization Program for Ambetter Health Members

PDS Transition to Waiver Operating Agency

[New York] Reimbursement policy update: Moderate (Conscious) Sedation — Professional and Facility

[Georgia] Reimbursement policy update: Moderate (Conscious) Sedation — Professional and Facility

Pasatru™ (Garetosmab-Grts)

Genglycos ™ (Pariglasgene Brecaparvovec-Opnr)

FDA Cleared or Approved Companion Diagnostic Testing (for Kentucky Only)

Ambulance Services (for Kentucky Only)

Spinal Fusion and Decompression (for Kentucky Only)

Obstructive and Central Sleep Apnea Treatment (for Kentucky Only)

[Georgia] Reimbursement policy update: Sleep Studies and Related Bundled Services and Supplies — Professional

[New York] Reimbursement policy update: Sleep Studies and Related Bundled Services and Supplies — Professional

Bevacizumab products

Bevacizumab products (New)

Orthotics - MEDICAID - KENTUCKY (Revised)

Orthotics - MEDICAID - KENTUCKY (Revised)

Genomic and Molecular Biomarker Testing for Cancer - MEDICAID - KENTUCKY (New)

Spinal Decompression Surgery - MEDICAID - KENTUCKY (New)

Update for CPT Codes 80320-80377: Effective 10/1/2026

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

Xolair ® (Omalizumab)

Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment Decisions (for Kentucky Only)

[New York] Reimbursement policy reminder: Provider Preventable Conditions — Professional and Facility

[Ohio] Reimbursement policy reminder: Provider Preventable Conditions — Professional and Facility