Oral Nutrition Mandate
Effective June 1, 2026, the medical criteria for milk/soy protein allergy will be revised for commercial products only. For additional details related to this policy, please click here.
Remote Electrical Neuromodulation for Migraines
Effective June 1, 2026, service will change from being not covered for Medicare Advantage plans and not medically necessary for commercial products to covered for Medicare Advantage plans and commercial products. For additional details related to this policy, please click here.
New Technology and Miscellaneous Services
Effective June 1, 2026, CPT code 0601T will be removed from this policy and will be added to medical policy, Prior Authorization of Services, Treatments or Procedures. For additional details related to this policy, please click here.
Prior Authorization of Services, Treatments or Procedures
Effective June 1, 2026, CPT code 0601T will continue to require prior authorization for Medicare Advantage plans and prior authorization will be recommended for commercial products. For additional details related to this policy, please click here.
Retinal Telescreening for Diabetic Retinopathy
Effective June 1, 2026, CPT codes 92228 and 92229 will change to covered for commercial products when utilized for the detection or monitoring of Diabetic Retinopathy. Category II CPT codes will change to optional for primary care providers and will continue to be optional for optometrists and ophthalmologists for Medicare Advantage plans and commercial products. For additional details related to this policy, please click here.
Focal Treatments for Prostate Cancer
Effective June 1, 2026, CPT code 55877 will be removed from this policy for both Medicare Advantage plans and commercial products and added to the new medical policy, Irreversible Electroporation (IRE) of Tumors Other Than Liver, with no change in coverage for Medicare or commercial. For additional details related to this policy, please click here.
Genetic Testing Services
Effective June 1, 2026, CPT codes 81462, 81463, 81464, the medical necessity criteria will change to Unlisted Genetic Testing criteria for participating providers for Medicare Advantage plans and commercial products. For additional details related to this policy, please click here.
Bariatric Surgery
Effective June 1, 2026, prior authorization will be required for Medicare Advantage Plans and will be recommended for Commercial Products for single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SAD-S) utilizing medical criteria in this policy. Coding guidance will be provided under the Coding section. Will be adding CPT code 43847 when utilized for long-limb gastric bypass, which will continue to be not medically necessary for Commercial Products only; when CPT code 43847 is utilized for Roux-en-Y, refer to the Related Policies section, which will have no changes. There will be no other changes. For additional details related to this policy, please click here.
Prior Authorization of Services, Treatments or Procedures
Effective June 1, 2026, prior authorization will continue for CPT code 43847 utilizing the medical criteria in the online tool when the code is utilized for the Roux-en-Y procedure for Medicare Advantage Plans and Commercial Products; however, when CPT code 43847 is utilized for long-limb gastric bypass, it will continue to be not medically necessary for Commercial Products only based on medical policy, Bariatric Surgery (above). For additional details related to this policy, please click here.