Updated Policies - Effective January 1, 2026

CP.MP.185

Skin and Soft Tissue Substitutes for Chronic Wounds

In policy statement I., specified that criteria is applicable to “up to four initial applications…”. Under criteria I.F. removed “FDA approved” and replaced with “labeled”. Added criteria I.G.-I.I. Created new policy statement II. and criteria for “beyond the initial four applications and up to a total of eight …”. In III.A., added that non medically necessary indications include usage not listed in section II. of the policy. Added the following to the table of HCPCS codes that do not support medical necessity:A2036, A2037, A2038, A2039, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4391, Q4392, Q4393, Q4394, Q4395, Q4396, Q4397. Removed Q4104 and Q4106 from list of codes not supported by medical necessity criteria, as they are on the preferred product list.

Medicaid; Medicare

CP.MP.188

Pediatric Oral Function Therapy

Updated Criteria I. to specify initial pediatric oral function therapy. Added Criteria I.B. regarding adequate treatment for any contributing underlying medical conditions…and documentation of an individualized treatment plan…Added Criteria II. regarding requirements for continuation of pediatric oral function therapy.

Medicaid; Medicare

CP.MP.247

Transplant Service Documentation Requirements

Annual review. Added notes under Description regarding plan-approved criteria for medical necessity criteria for solid organ and stem cell transplant requests and criteria applicable to Medicare plans. Added transplant consultation to Criteria I. Updated verbiage in Criteria I.A.2. for clarity. Changed criteria I.A.2.a.-c. into a note.  Added additional note under Criteria I.A.2.c. regarding evaluation requests for sickle cell anemia and beta thalassemia. Updated Criteria I.B. to specify initial and subsequent autologous stem cell transplants or initial and subsequent allogeneic stem cell or solid organ transplant listing requests. Updated verbiage in Criteria I.B.4. for clarity. Removed BMI from Criteria I.B.5.e. since BMI is addressed in Criteria I.B.3.c. Updated Criteria I.B.5.g. to include lumbar puncture when clinically indicated. Verbiage updated in Criteria I.B.6. for clarity. Updated verbiage in Criteria I.B.7. to “breast cancer screening”, “cervical cancer screening,” and “colon cancer screening” and removed note that routine health screenings per standards of care are not required for autologous stem cell transplants. Removed “including cardiology” from Criteria I.B.8. Added Criteria I.B.9. regarding cardiology testing/clearance. Removed verbiage specifying only solid organ or allogeneic stem cell transplants in Criteria I.B.11. Updated verbiage in Criteria I.B.11., I.B.11.f., and I.B.11.h. for clarity. Updated verbiage in Criteria I.D., I.D.2., and I.D.3. for clarity. Background updated with no impact to criteria. References reviewed and updated. Reviewed by internal specialist.

Medicaid; Medicare

CP.MP.248

Facility-based Sleep Studies for Obstructive Sleep Apnea

Annual review. Description updated to include titration polysomnography (PSG) for hypoglossal nerve stimulation (HNS). Added clarifying language in Criteria I.B.6. with no impact on criteria. Updated verbiage in Criteria I.B.7. for clarity with no impact to criteria. Added Criteria IV. to include titration PSG for HNS. Added “non-Medicare” verbiage in Criteria V. for clarification. Background updated to include information regarding titration PSG for HNS. Coding and descriptions reviewed. References reviewed and updated. Reviewed by internal specialist and external specialist.

Medicaid; Medicare