PAYER POLICY CHANGES

New Jersey Medicaid Policy Changes

Policy changes from New Jersey Medicaid and from Medicaid managed care plans in New Jersey, with the Medicaid prior authorization lists and payer contacts we track for the state. Each item links to its public source.

UnitedHealthcare · Effective Nov 1, 2026Medium impact
Annual ICD-10 and Quarterly CPT/HCPCS Code Updates (Medicaid, NJ)
UnitedHealthcare Community Plan of New Jersey (Medicaid) updated its medical policies effective November 1, 2026 to reflect annual ICD-10 and quarterly CPT/HCPCS code additions and deletions across several New Jersey-only policies, including autologous cellular therapy, cell-free fetal DNA testing, electrical stimulation, gender dysphoria treatment, hereditary cancer genetic testing, lower extremity endovascular procedures, molecular oncology testing, sleep apnea treatment, and respiratory pathogen testing. Billing staff should update charge master and claim-entry code lists so that added codes are available and deleted codes are removed for New Jersey Medicaid members' claims.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Saphnelo® (Anifrolumab-Fnia)
UnitedHealthcare Community Plan of New Jersey revised its Saphnelo (anifrolumab-fnia) IV medical policy, effective 2027-01-01. A new continuation and initial criterion requires the prescriber to attest that the patient or caregiver cannot be trained or is physically unable to self-administer Saphnelo or Benlysta, with an explanation submitted, and initial and continuation authorizations are limited to no more than 12 months. Saphnelo for severe active lupus nephritis, severe active CNS lupus, or use with other biologics is listed as not medically necessary.
UnitedHealthcare · Effective Dec 1, 2026Low impact
Pasatru™ (Garetosmab-Grts)
UnitedHealthcare Community Plan of New Jersey added a Medicaid medical benefit drug policy for Pasatru (garetosmab-grts) for fibrodysplasia ossificans progressiva (FOP), effective 2026-12-01. Initial therapy requires an age over 18, an FOP diagnosis, supporting chart notes and ACVR1 genetic testing, prescribing by or in consultation with an FOP expert, FDA-labeled dosing, no combination with Sohonos (palovarotene), and authorization for no more than 12 months; continuation requires documented positive response and renewal for no more than 12 months.
UnitedHealthcare · Effective Dec 1, 2026Low impact
Genglycos ™ (Pariglasgene Brecaparvovec-Opnr)
UnitedHealthcare Community Plan of New Jersey published a new 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 aged 8 or older with a confirmed GSDIa diagnosis (G6PC bi-allelic variants or absent G6Pase activity on liver biopsy), on a current cornstarch regimen, without detectable AAV8 antibodies, no prior gene therapy, prescribed by or with a metabolic specialist, no planned inpatient admission solely for administration, dosed per FDA labeling, and authorized for one lifetime treatment for up to 45 days from approval.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
FcRn Blockers
UnitedHealthcare Community Plan of New Jersey revised its FcRn Blockers medical benefit drug policy, expanding coverage for Imaavy (nipocalimab-aahu) in warm autoimmune hemolytic anemia (wAIHA) in adults and pediatric patients 12 and older who are currently or previously treated with corticosteroids. Billing teams should expect new medical-record documentation requirements (confirmed diagnosis, DAT results, prescriber involvement, and prior treatment history), a 12-month initial authorization limit, and the addition of ICD-10 code D59.11 to applicable diagnosis codes.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey revised its Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) medical policy for New Jersey Medicaid, effective 2027-01-01. Revisions include broadening who may order the test to 'by or in consultation with' a medical geneticist, neonatologist, neurologist, immunologist, or developmental pediatrician, adding criteria for exome and genome data reanalysis after at least 18 months, restricting the policy to outpatient testing or testing upon discharge from an inpatient setting, and adding CPT codes 0670U through 0677U. The policy also notes that CPT codes 0657U, 0658U, 0659U, 0670U-0677U, and 81354 are not on the New Jersey Medicaid fee schedule and may not be covered by the New Jersey Medicaid program.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Video Electroencephalographic (vEEG) Monitoring and Recording (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey retired its medical policy on video electroencephalographic (vEEG) monitoring and recording, effective 2026-11-01. Claims for vEEG monitoring and recording for New Jersey Medicaid members no longer require clinical review under this policy.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Vascular Embolization: Select Procedures (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey's November 2026 Medicaid medical policy bulletin adds a new policy, effective 2026-12-01, on vascular embolization for select procedures. Renal embolization is covered as medically necessary for preoperative or palliative treatment of renal cell carcinoma and for nonruptured angiomyolipomas at elevated bleeding risk, while transarterial bland embolization or chemoembolization for liver malignancies follows InterQual criteria and other oncologic indications follow NCCN guidelines. Arterial embolization for hemorrhoids and for musculoskeletal pain (knee and shoulder osteoarthritis, adhesive capsulitis, tendinitis, plantar fasciitis) is labeled unproven and not medically necessary, and the policy excludes members under 18 and acute or active bleeding indications.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Surgery of the Elbow (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey retired its medical policy for surgery of the elbow, so elbow surgery for these New Jersey Medicaid members no longer requires clinical review under this policy. The retirement is shown with an effective date of 2026-11-01 in the November 2026 bulletin.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey updated its Medicaid medical policy on Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery, revising the definition of oligometastatic disease and refreshing the clinical evidence and references supporting the policy. Billing teams serving New Jersey Community Plan Medicaid members should review their radiation oncology and radiosurgery claim workflows against the revised definition and the updated policy text.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey's November 2026 medical policy bulletin updates the Occipital Nerve Injections and Ablation policy for New Jersey Medicaid members: CPT codes 1057T, 1058T, 1059T, 1060T and 1061T are added, and CPT 64570 is removed. The bulletin notes that the newly added codes are not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by the New Jersey Medicaid Program. The billing team should verify coverage status before scheduling or billing these services for affected members.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Molecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment Decisions (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey revised its Medicaid medical policy for molecular oncology testing in hematologic cancers, effective 2027-01-01. Multigene panel testing of up to 50 genes is covered when ordered by a hematologist or oncologist at initial diagnosis or relapse for listed conditions (adding mantle cell lymphoma), clonoSEQ clonality and MRD testing is covered for listed conditions, and CPT codes 0332U, 0592U, 0644U and 0645U were added while 0485U, 0560U and 0561U were removed; all other molecular oncology testing is stated as unproven and not medically necessary, including EpiSwitch Checkpoint Inhibitor Response Test, optical genome mapping and whole-transcriptome sequencing.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Facet Joint and Medial Branch Block Injections for Spinal Pain (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey updated its Medicaid medical policy for facet joint and medial branch block injections for spinal pain, effective 2026-11-01. The update removes the Medical Records Documentation Used for Reviews section from the policy and points to the payer's provider website for that information, so billing teams should pull the current documentation guidance from UHCprovider.com before preparing records for these injections.
UnitedHealthcare · Effective Nov 1, 2026Low impact
Epidural Steroid Injections for Spinal Pain (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey updated its Epidural Steroid Injections for Spinal Pain medical policy for New Jersey Medicaid members, effective 2026-11-01. The only change listed is a template update that removed the Medical Records Documentation Used for Reviews section; that documentation guidance now lives on UHCprovider.com under Community Plans > Resources and FAQs > Medical Records Documentation Used for Reviews. Billing teams should pull that linked resource so claim-supporting documentation for these injections stays aligned with current payer expectations.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Bariatric Surgery (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey updated its Bariatric Surgery medical policy in its November 2026 bulletin, 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 documentation guidance now referenced on UHCprovider.com under Community Plans > Resources and FAQs.
UnitedHealthcare · Effective Nov 1, 2026Low impact
Abnormal Uterine Bleeding and Uterine Fibroids (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey updated its Abnormal Uterine Bleeding and Uterine Fibroids medical policy for New Jersey Medicaid members, effective 2026-11-01. The update removed the Medical Records Documentation Used for Reviews section, which now lives on UHCprovider.com under Community Plans > Resources and FAQs, and refreshed the Clinical Evidence and References sections.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Medicaid: Expanded prior auth reductions for NE, NJ and TN
UnitedHealthcare Community Plans is removing prior authorization requirements for select procedure codes in Nebraska (effective Nov. 1, 2026), New Jersey (effective Dec. 1, 2026), and Tennessee (effective Dec. 1, 2026). Billing teams in these states must identify which codes no longer require prior auth and stop submitting prior authorization requests for those procedures.
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.
UnitedHealthcare · Identified Nov 2, 2026Medium impact
NJ Medicaid: Consent form required with sterilization claims
UnitedHealthcare Community Plan of New Jersey now requires a completed, signed Consent Form 7473-M ED 3-81 to be submitted with all sterilization procedure claims (hospital, physician, anesthesiology, and clinic). Claims submitted without this form will be denied.
UnitedHealthcare · Effective Apr 1, 2026Medium impact
New Jersey Medicaid: Discover new program for serious illness care
UnitedHealthcare Community Plan of New Jersey launched a new Community-Based Palliative Care (CBPC) program for New Jersey FamilyCare members effective April 1, 2026. Providers must enroll in the CBPC network to bill the PMPM bundle (code S0311) and avoid claim denials; initial assessments (S0280) and reassessments (S0281) have specific documentation and prior authorization requirements.
Horizon BCBS NJ · Identified Oct 3, 2026Low impact
Receive and Send Documents Electronically with HorizonDocs
Horizon Blue is promoting HorizonDocs, a web-based secure document repository for electronic submission and receipt of documentation requests. This is an optional tool that allows providers to centrally manage document exchanges with Horizon, organized by category and member/tax ID, with role-based access controls and email notifications.
Horizon BCBS NJ · Identified Oct 3, 2026High impact
Use In-Network Labs for Patient Services
Horizon Blue Cross Blue Shield of New Jersey is mandating that all laboratory services be directed to in-network preferred labs (LabCorp, Quest Diagnostics, BioReference Laboratories) across their commercial, Medicaid, and Medicare Advantage plans. Specific labs including Natera, Sema4/GeneDx, Invitae, Myriad Genetics, Sherman Abrams Laboratory, and Clarity Labs are now out-of-network and should not be used. Billing teams must update lab referral protocols and specimen routing to avoid claim denials.
Horizon BCBS NJ · Identified Oct 3, 2026Low impact
Send Requested Medical Records and Post Service Appeals Quicker with HorizonDocs
Horizon Blue is promoting HorizonDocs, a web-based centralized document repository for secure exchange of medical records, appeals, and other documentation between providers and Horizon. This is an optional tool designed to streamline post-service appeals and medical records requests with HIPAA-compliant document management and permission-based access controls.
Horizon BCBS NJ · Identified Oct 3, 2026Medium impact
New Provider Portal: Availity Essentials Coming Soon
Horizon Blue is transitioning from NaviNet to Availity Essentials as the new secure provider portal for all Horizon, Braven Health, and Horizon NJ Health members. The transition will occur in phases throughout spring 2024, with NaviNet remaining available during the transition period. Billing teams must prepare to migrate portal workflows and claims submission processes to the new platform.
Horizon BCBS NJ · Effective Jan 1, 2026High impact
Risk Adjustment Data Validation Audits to Resume in 2026
CMS will resume Risk Adjustment Data Validation (RADV) audits in 2026, beginning with payment year 2020 claims dating back to 2017. These audits verify that submitted diagnoses are supported by complete, signed medical record documentation. Providers must ensure timely submission of requested medical records to avoid diagnosis disallowance, financial penalties, and potential program exclusion from Medicare Advantage, ACA, or Medicaid.
Horizon BCBS NJ · Effective Jun 1, 2026High impact
Claim Dispute Submission Changes Effective June 1, 2026
Effective June 1, 2026, Horizon Blue Cross Blue Shield will no longer accept claim disputes submitted by phone for Horizon NJ Health (Medicaid) and Federal Employee Program (FEP) members. All claim disputes must be submitted through the Provider Portal (Availity Essentials). Claim appeals remain unchanged and must continue to be submitted in writing.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Evenity ® (Romosozumab-Aqqg)
UnitedHealthcare Community Plan of New Jersey expanded Evenity® (Romosozumab-Aqqg) coverage criteria effective November 1, 2026 to include patients with very high fracture risk (recent fractures, fractures on therapy, multiple fractures, BMD T-score <-3.0, fall risk, or elevated FRAX scores ≥30% major fracture/≥4.5% hip fracture). Coverage remains limited to 12 months maximum with specific exclusions for combination therapies and requires documentation of medical necessity.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Antiemetics for Oncology
UnitedHealthcare Community Plan of New Jersey (Medicaid) updated its Antiemetics for Oncology policy effective November 1, 2026. The policy revised coverage criteria to add 'less than 7 hours of sleep the night before chemotherapy' as a new risk factor for chemotherapy-induced nausea/vomiting and replaced 'high anxiety' with 'anxiety/high pretreatment expectation of nausea.' These changes may broaden eligibility for NK1 RA and combination antiemetic products when used with moderate emetic risk agents.
UnitedHealthcare · Effective Oct 1, 2026Medium impact
Virtual Upper Gastrointestinal Endoscopy (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey has retired its policy requiring clinical review for virtual upper gastrointestinal endoscopy procedures. Effective October 1, 2026, virtual upper GI endoscopy no longer requires prior authorization or clinical review before billing.
UnitedHealthcare · Effective Dec 1, 2026High impact
Treatment of Temporomandibular Joint Disorders (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey has narrowed TMJ surgical coverage to only arthroplasty (removing arthroscopy, discectomy, and reconstruction from covered services) and updated clinical coverage criteria references for Medicaid beneficiaries in New Jersey. Four CPT codes (21060, 21247, 29800, 29804) have been removed from applicable codes, effective December 1, 2026.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey (Medicaid) revised coverage criteria for Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) using yttrium-90 microspheres effective December 1, 2026. The policy now specifies five covered indications for liver cancer treatment (including a change from 'uveal/ocular melanoma metastasis' to 'uveal melanoma metastasis'), applies only to patients age 19+ with ECOG Performance Status 0-2, and automatically covers patients under 19 without prior authorization.
UnitedHealthcare · Effective Oct 1, 2026Medium impact
Pharmacogenetic Panel Testing (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey updated its pharmacogenetic panel testing policy effective October 1, 2026, adding CPT code 0697U to the applicable codes list and clarifying that CPT codes 0650U and 0652U are NOT covered under New Jersey Medicaid Fee Schedule. The clinical evidence and references sections were also updated to reflect current information.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Injectable Dermal Fillers and Bulking Agents (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey has removed CPT codes 31570, 31571, and 31574 from coverage under the Injectable Dermal Fillers and Bulking Agents policy, effective November 1, 2026. The policy also updated supporting clinical evidence and references. Billing teams must stop using these codes for New Jersey Medicaid members on or after this date.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey updated re-evaluation requirements for habilitation and rehabilitation therapy (occupational, physical, and speech). Re-evaluations must now occur at least once every 6 months instead of 12 months, effective November 1, 2026. This change applies to New Jersey Medicaid members only.
UnitedHealthcare · Effective Dec 1, 2026High impact
Cardiovascular Disease Risk Tests (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey (Medicaid) revised its coverage policy for cardiovascular disease risk tests, effective December 1, 2026. The policy narrowed the exclusion for advanced lipoprotein analysis (now excluding only subfractions/particle size, not lipoprotein(a)), added exclusion for noninvasive point-of-care cardiac diagnostic platforms using machine learning (e.g., CorVista System), updated applicable CPT codes, and removed CPT 83695 from the billable codes list.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Breast Imaging for Screening and Diagnosing Cancer (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey (Medicaid) revised its breast imaging policy effective December 1, 2026, clarifying coverage criteria for breast MRI in high-risk individuals and refining the list of unproven/non-covered modalities. Key changes include refined definitions of Molecular Breast Imaging and removal of Breast Specific Gamma Imaging as a separate definition. Breast MRI is now clearly covered for specific high-risk populations including those with dense breasts, genetic mutations, personal/family history of breast cancer, and prior chest radiation—but remains non-covered for individuals who do not meet these criteria.
UnitedHealthcare · Identified Oct 1, 2026Low impact
Tell us how we’re doing: Satisfaction survey is live
UnitedHealthcare is conducting a Community and State (Medicaid) Provider Satisfaction Survey to gather feedback on digital tools and the Provider Portal. Providers in 16 states and Washington, D.C. are invited to participate by October 23, 2026. This is a feedback collection initiative, not a billing or coverage policy change.
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.
New Jersey Medicaid · Effective Jan 1, 2027High impact
Newsletter Vol. 36, No.09
New Jersey Medicaid/NJ FamilyCare mandates that Personal Care Assistance (PCA) and Home Health Services (HHS) providers must achieve 80% Electronic Visit Verification (EVV) compliance by January 1, 2027, with no more than 20% manual edits allowed. Providers failing to meet this threshold face progressive sanctions including loss of new referrals, contract termination, and one-year ineligibility. The policy includes a three-month compliance period (October 1 – December 31, 2026) and defines six required EVV data elements with specific edit reason codes.
UnitedHealthcare · Effective Oct 1, 2026Medium impact
Zolgensma® (Onasemnogene Abeparvovec-Xioi)
UnitedHealthcare Community Plan of New Jersey revised Zolgensma® (Onasemnogene Abeparvovec-Xioi) coverage criteria effective October 1, 2026. The key change removes the absolute prohibition on concurrent SMN-modifying therapy (Evrysdi, Spinraza) and instead requires medical record review; any existing SMN therapy authorizations will be terminated upon Zolgensma approval. All other eligibility criteria remain stringent, including age restrictions (under 2 years), genetic confirmation, anti-AAV9 antibody testing, and one-lifetime treatment authorization.
UnitedHealthcare · Effective Oct 1, 2026Medium impact
Xolair ® (Omalizumab)
UnitedHealthcare Community Plan of New Jersey revised Xolair (Omalizumab) coverage criteria effective October 1, 2026. Key changes include: (1) Added Exdensur (depemokimab) to the list of anti-interleukin 5 therapies that cannot be used in combination with Xolair across all four indications; (2) For Chronic Urticaria, added new requirement that patients must fail at least 2 weeks of standard-dosed 2nd generation H1-antihistamine AND 2 weeks of up-to-4-fold dose escalation before Xolair approval; (3) Added Nucala (mepolizumab) to the Chronic Urticaria combination therapy restrictions. Billing teams must verify patient therapy history and document prior antihistamine trials before submitting claims.
UnitedHealthcare · Effective Oct 1, 2026Medium impact
Tzield® (Teplizumab-Mzwv)
UnitedHealthcare Community Plan of New Jersey (Medicaid) revised coverage criteria for Tzield® (Teplizumab-Mzwv) effective October 1, 2026. Key changes include: (1) for Stage 2 T1D patients, replaced the requirement to rule out T2D with a clinical history assessment excluding insulin resistance/other diabetes forms, and clarified lifetime authorization as 'one 14-dose treatment course'; (2) added new coverage for pediatric patients aged 8-17 with recently diagnosed Stage 3 T1D, allowing up to two 12-dose treatment courses per lifetime. Added multiple ICD-10 diagnosis codes for Type 1 Diabetes.
UnitedHealthcare · Effective Oct 1, 2026Medium impact
Otarmeni™ (Lunsotogene Parvec-Cwha)
UnitedHealthcare Community Plan of New Jersey (Medicaid) has added coverage for Otarmeni™ (Lunsotogene Parvec-Cwha), a gene therapy treatment for pediatric and adult patients with severe-to-profound sensorineural hearing loss caused by biallelic OTOF gene variants. Coverage requires strict medical necessity criteria including molecular confirmation, preserved outer hair cell function, no prior cochlear implant in the same ear, and feasible inner ear access on imaging. Authorization is limited to one treatment per ear per lifetime with a 60-day approval window.
UnitedHealthcare · Effective Oct 1, 2026Medium impact
Lumvoa ™ (Veligrotug-Vvze) and Tepezza® (Teprotumumab-Trbw)
UnitedHealthcare Community Plan of New Jersey (Medicaid) has revised coverage criteria for Lumvoa and Tepezza, two biologic treatments for thyroid eye disease. Key changes include: (1) Lumvoa is now covered with specific clinical criteria and limited to a maximum of 5 lifetime doses; (2) Tepezza now requires that patients have not previously received Lumvoa, and remains limited to 8 lifetime doses; (3) two HCPCS codes (J3490 and J3590) have been added for billing these drugs. Treatment exceeding lifetime dose limits is considered unproven and not medically necessary.
UnitedHealthcare · Effective Oct 1, 2026Medium impact
Itvisma® (Onasemnogene Abeparvovec-Brve)
UnitedHealthcare Community Plan of New Jersey revised coverage criteria for Itvisma (gene therapy for spinal muscular atrophy) effective October 1, 2026. The key change removes automatic termination of concomitant SMN-modifying therapies upon Itvisma approval; instead, only medical record review is required. This softens the previous exclusionary criterion, potentially allowing continued use of therapies like Evrysdi or Spinraza in some cases pending clinical review.
UnitedHealthcare · Effective Nov 1, 2026High impact
Spinal Fusion and Decompression (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey updated its spinal fusion and decompression coverage policy effective November 1, 2026. Key changes include: (1) Updated medical necessity criteria to reference the InterQual® Client Defined, CP: Procedures, Decompression +/- Fusion, Lumbar (Custom) - UHG instead of the standard InterQual® criteria; (2) Added new definitions for Anticipated Instability Due to Procedure, Instability, and Lumbar Spinal Decompression; (3) Clarified that staged/serial procedures for multisite spinal pathology in one session are unproven and not medically necessary; and (4) Reaffirmed that dynamic stabilization systems, facet joint replacement, isolated facet joint fusion, and vertebral joint implants are not covered.
UnitedHealthcare · Effective Sep 1, 2026Medium impact
Outpatient Surgical Procedures – Site of Service (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey updated its outpatient surgical procedures policy to strengthen medical records documentation requirements. The policy now explicitly requires that patient records contain legible documentation supporting medical necessity (including relevant medical history, physical examination, and diagnostic test results) before coverage can be approved, and clarifies that documentation requirements do not guarantee coverage. The plan also removed a reference link to the TMJ disorders policy and updated the definition of 'Poorly Controlled Hypertension.'
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Obstructive and Central Sleep Apnea Treatment (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey updated its OSA treatment policy to add radiofrequency ablation of the soft palate and/or tongue base to the list of unproven and not medically necessary procedures, effective November 1, 2026. This policy applies to NJ Medicaid members only and affects coverage determinations for both surgical and non-surgical sleep apnea treatments.
UnitedHealthcare · Effective Sep 1, 2026Medium impact
Glaucoma Surgical Treatments (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey has updated its Glaucoma Surgical Treatments policy, effective September 1, 2026. CPT code 1012T is now flagged as NOT covered by the State of New Jersey Medicaid Fee Schedule and may not be reimbursed. The policy also updated clinical evidence and supporting documentation.
UnitedHealthcare · Effective Sep 1, 2026Medium impact
Genetic Testing for Neurological Disorders (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey updated its Genetic Testing for Neurological Disorders policy effective September 1, 2026. Key changes include: removal of reference links to related policies (Chromosome Microarray Testing and Genetic Testing for Cardiac Disease), simplification of testing terminology (removed "multi-gene" descriptor), deletion of WES/WGS definitions, and updates to clinical evidence and supporting information. Billing teams must review updated coverage rationale and testing terminology to ensure accurate claims submission.

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Annual ICD-10 and Quarterly CPT/HCPCS Code Updates (Medicaid, NJ)

Saphnelo® (Anifrolumab-Fnia)

Pasatru™ (Garetosmab-Grts)

Genglycos ™ (Pariglasgene Brecaparvovec-Opnr)

FcRn Blockers

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

Video Electroencephalographic (vEEG) Monitoring and Recording (for New Jersey Only)

Vascular Embolization: Select Procedures (for New Jersey Only)

Surgery of the Elbow (for New Jersey Only)

Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for New Jersey Only)

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

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

Facet Joint and Medial Branch Block Injections for Spinal Pain (for New Jersey Only)

Epidural Steroid Injections for Spinal Pain (for New Jersey Only)

Bariatric Surgery (for New Jersey Only)

Abnormal Uterine Bleeding and Uterine Fibroids (for New Jersey Only)

Medicaid: Expanded prior auth reductions for NE, NJ and TN

Medicaid: New policy for select embolization procedures

NJ Medicaid: Consent form required with sterilization claims

New Jersey Medicaid: Discover new program for serious illness care

Receive and Send Documents Electronically with HorizonDocs

Use In-Network Labs for Patient Services

Send Requested Medical Records and Post Service Appeals Quicker with HorizonDocs

New Provider Portal: Availity Essentials Coming Soon

Risk Adjustment Data Validation Audits to Resume in 2026

Claim Dispute Submission Changes Effective June 1, 2026

Evenity ® (Romosozumab-Aqqg)

Antiemetics for Oncology

Virtual Upper Gastrointestinal Endoscopy (for New Jersey Only)

Treatment of Temporomandibular Joint Disorders (for New Jersey Only)

Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver (for New Jersey Only)

Pharmacogenetic Panel Testing (for New Jersey Only)

Injectable Dermal Fillers and Bulking Agents (for New Jersey Only)

Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for New Jersey Only)

Cardiovascular Disease Risk Tests (for New Jersey Only)

Breast Imaging for Screening and Diagnosing Cancer (for New Jersey Only)

Tell us how we’re doing: Satisfaction survey is live

New oncology prior authorization code updates

Newsletter Vol. 36, No.09

Zolgensma® (Onasemnogene Abeparvovec-Xioi)

Xolair ® (Omalizumab)

Tzield® (Teplizumab-Mzwv)

Otarmeni™ (Lunsotogene Parvec-Cwha)

Lumvoa ™ (Veligrotug-Vvze) and Tepezza® (Teprotumumab-Trbw)

Itvisma® (Onasemnogene Abeparvovec-Brve)

Spinal Fusion and Decompression (for New Jersey Only)

Outpatient Surgical Procedures – Site of Service (for New Jersey Only)

Obstructive and Central Sleep Apnea Treatment (for New Jersey Only)

Glaucoma Surgical Treatments (for New Jersey Only)

Genetic Testing for Neurological Disorders (for New Jersey Only)