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| Item Number | Policy/Procedure | Date Posted | Comment Period Closed | Status | Document Links |
|---|---|---|---|---|---|
| 2025-LHCC-966 | Cultural and Linguistic Policy | 10/15/25 | 11/29/25 | Approved | Cultural and Linguistic Policy |
| 2025-HUM-1460 | Doula Services (ILO) | 10/15/25 | 11/29/25 | Approved | Doula Services (ILO) |
| 2025-ABH-2363 | AMA XXXX Hospice | 10/15/25 | 11/29/25 | Approved | AMA XXXX Hospice |
| 2025-HBL-2748 | Carelon Trans to Vsclr Emblztn-Occlsn Prcdrs | 10/15/25 | 11/29/25 | Approved | Carelon Trans to Vsclr Emblztn-Occlsn Prcdrs |
| 2025-HBL-1033 | Therapeutic Apheresis | 10/10/25 | 11/24/25 | Approved | Therapeutic Apheresis |
| 2025-UHC-1123 | Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds | 10/10/25 | 11/24/25 | Approved | Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds |
| 2025-UHC-1589 | Surgical Treatment of Lymphedema | 10/10/25 | 11/24/25 | Approved | Surgical Treatment of Lymphedema |
| 2025-UHC-1762 | Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery | 10/10/25 | 11/24/25 | Approved | Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery |
| 2025-UHC-486 | Abnormal Uterine Bleeding and Uterine Fibroids | 10/6/25 | 11/20/25 | Approved | Abnormal Uterine Bleeding and Uterine Fibroids |
| 2025-UHC-793 | Virtual Upper Gastrointestinal Endoscopy | 10/6/25 | 11/20/25 | Approved | Virtual Upper Gastrointestinal Endoscopy |
| 2025-LHCC-1273 | Orthognathic Surgery | 10/6/25 | 11/20/25 | Approved | Orthognathic Surgery |
| 2025-LHCC-1277 | Panniculectomy | 10/6/25 | 11/20/25 | Approved | Panniculectomy |
| 2025-LHCC-1361 | Pediatric Heart Transplant | 10/6/25 | 11/20/25 | Approved | Pediatric Heart Transplant |
| 2025-LHCC-1741 | AHCT for Sickle Cell Anemia and Thalassemia | 10/6/25 | 11/20/25 | Approved | AHCT for Sickle Cell Anemia and Thalassemia |
| 2025-LHCC-1842 | Cosmetic and Reconstructive Procedures | 10/6/25 | 11/20/25 | Approved | Cosmetic and Reconstructive Procedures |
| 2025-UHC-2311 | Injectable Dermal Fillers and Bulking Agents | 10/6/25 | 11/20/25 | Approved | Injectable Dermal Fillers and Bulking Agents |
| 2025-LHCC-2749 | Radiation Therapy for Skin Cancer | 10/6/25 | 11/20/25 | Approved | Radiation Therapy for Skin Cancer |
| 2025-LHCC-1743 | Hospice Services | 9/29/25 | 11/13/25 | Pending | Hospice Services |
| 2025-LHCC-1959 | BH Treatment Documentation Requirements | 9/29/25 | 11/13/25 | Pending | BH Treatment Documentation Requirements |
| 2025-ABH-2536 | Community Brief Crisis Support (CBCS) and Behavioral Health Crisis Care (BHCC) Policy | 9/29/25 | 11/13/25 | Pending | Community Brief Crisis Support (CBCS) and Behavioral Health Crisis Care (BHCC) Policy |
| 2025-ABH-822 | ABH Provider Manual | 9/29/25 | 11/13/25 | Pending | ABH Provider Manual |
| 2025-ABH-1891 | Member Appeals | 9/29/25 | 11/13/25 | Pending | Member Appeals |
| 2025-ABH-1892 | Member Grievance | 9/29/25 | 11/13/25 | Pending | Member Grievance |
| 2025-LHCC-2476 | In Lieu Of Services Remote Patient Monitoring | 9/29/25 | 11/13/25 | Pending | In Lieu Of Services Remote Patient Monitoring |
| 2025-LHCC-1491 | NCCI Unbunding | 9/29/25 | 11/13/25 | Approved | NCCI Unbunding |
| 2025-LHCC-2530 | Transportation Policy | 9/29/25 | 11/13/25 | Pending | Transportation Policy |
| 2025-LHCC-687 | Measurable Progressive Improvement | 9/29/25 | 11/13/25 | Pending | Measurable Progressive Improvement |
| 2025-LHCC-931 | Appeals Process | 9/29/25 | 11/13/25 | Pending | Appeals Process |
| 2025-LHCC-1378 | Wheelchair Seating | 9/29/25 | 11/13/25 | Pending | Wheelchair Seating |
| 2025-LHCC-1410 | Neurofeedback for Behavioral Health Disorders | 9/29/25 | 11/13/25 | Pending | Neurofeedback for Behavioral Health Disorders |
| 2025-LHCC-1480 | Pre-operative Visits | 9/29/25 | 11/13/25 | Pending | Pre-operative Visits |
| 2025-LHCC-1908 | Community Brief Crisis Support | 9/29/25 | 11/13/25 | Pending | Community Brief Crisis Support |
| 2025-HUM-1922 | UM Home Health Clinical Coverage Policy | 9/29/25 | 11/13/25 | Pending | UM Home Health Clinical Coverage Policy |
| 2025-ABH-2254 | Benefit Exception Amendment | 9/29/25 | 11/13/25 | Pending | Benefit Exception Amendment |
| 2025-HUM-2565 | Drugs and Biologicals HCPCS | 9/29/25 | 11/13/25 | Pending | Drugs and Biologicals HCPCS |
| 2025-LHCC-2667 | MediTrans Claims Manual9/29/25 | 9/29/25 | 11/13/25 | Pending | MediTrans Claims Manual |
| 2025-ACLA-2727 | MH-IOP | 9/29/25 | 11/13/25 | Pending | MH-IOP |
| 2025-HUM-2728 | Correct Coding | 9/29/25 | 11/13/25 | Pending | Correct Coding |
| 2025-HUM-2729 | Correct Coding | 9/29/25 | 11/13/25 | Pending | Correct Coding |
| 2025-HUM-2740 | Anesthesia | 9/29/25 | 11/13/25 | Pending | Anesthesia |
| 2025-LHCC-1507 | Clinical Validation of Modifier 59 | 9/19/25 | 11/3/25 | Approved | Clinical Validation of Modifier 59 |
| 2025-LHCC-1509 | Clinical Validation of Modifier 25 | 9/19/25 | 11/3/25 | Approved | Clinical Validation of Modifier 25 |
| 2025-HUM-1644 | Eyebrow and Eyelid Repair | 9/19/25 | 11/3/25 | Approved | Eyebrow and Eyelid Repair |
| 2025-HUM-1661 | Molecular Diagnostic Assays and Breath Testing for Transplant Rejection Clinical Coverage Policy | 9/19/25 | 11/3/25 | Approved | Molecular Diagnostic Assays and Breath Testing for Transplant Rejection Clinical Coverage Policy |
| 2025-UHC-206 | Electric Tumor Treatment Field Therapy | 9/11/2025 | 10/26/2025 | Approved | Electric Tumor Treatment Field Therapy |
| 2025-UHC-222 | Skin and Soft Tissue Substitutes | 9/11/2025 | 10/26/2025 | Approved | Skin and Soft Tissue Substitutes |
| 2025-UHC-311 | Transcatheter Heart Valve Procedures | 9/11/2025 | 10/26/2025 | Approved | Transcatheter Heart Valve Procedures |
| 2025-UHC-379 | Brow Ptosis and Eyelid Repair | 9/11/2025 | 10/26/2025 | Approved | Brow Ptosis and Eyelid Repair |
| 2025-UHC-524 | Durable Medical Equipment, Orthotics, Medical Supplies and Repairs/Replacements | 9/11/2025 | 10/26/2025 | Approved | Durable Medical Equipment, Orthotics, Medical Supplies and Repairs/Replacements |
| 2025-UHC-558 | Surgery of the Knee | 9/11/2025 | 10/26/2025 | Approved | Surgery of the Knee |
| 2025-UHC-559 | Implantable Beta-Emitting Microspheres | 9/11/2025 | 10/26/2025 | Approved | Implantable Beta-Emitting Mocrospheres |
| 2025-UHC-561 | Cognitive Rehabilitation | 9/11/2025 | 10/26/2025 | Approved | Cognitive Rehabilitation |
| 2025-UHC-579 | Surgery of the Hip | 9/11/2025 | 10/26/2025 | Approved | Surgery of the Hip |
| 2025-UHC-1399 | Glaucoma Surgical Treatment | 9/11/2025 | 10/26/2025 | Approved | Glaucoma Surgical Treatment |
| 2025-UHC-1418 | Autologous Cellular Therapy | 9/11/2025 | 10/26/2025 | Approved | Autologous Cellular Therapy |
| 2025-UHC-1426 | Genetic Testing for Cardiac Disease | 9/11/2025 | 10/26/2025 | Approved | Genetic Testing for Cardiac Disease |
| 2025-UHC-2188 | Mandatory Medicaid Coverage of Routine Patient Costs in Qualifying Clinical Trials | 9/11/2025 | 10/26/2025 | Approved | Mandatory Medicaid Coverage of Routine Patient Costs in Qualifying Clinical Trials |
| 2025-UHC-2252 | Hospital Services: Observation and Inpatient | 9/11/2025 | 10/26/2025 | Approved | Clinical Policy Guidelines |
| 2025-ACLA-2745 | Clinical Policy Guidelines | 9/11/2025 | 10/26/2025 | Approved | Hospital Services: Observation and Inpatient |
| 2025-LHCC-690 | Outpatient Habilitative and Rehabilitative Speech Therapy | 9/3/25 | 10/18/25 | Approved | Outpatient Habilitative and Rehabilitative Speech Therapy |
| 2025-LHCC-1109 | Diaphragmatic/Phrenic Nerve Stimulation | 9/2/25 | 10/17/25 | Approved | Diaphragmatic/Phrenic Nerve Stimulation |
| 2025-LHCC-1228 | Sacroiliac Joint Interventions for Pain Management | 9/2/25 | 10/17/25 | Approved | Sacroiliac Joint Interventions for Pain Management |
| 2025-LHCC-1265 | Vagus Nerve Stimulation | 9/2/25 | 10/17/25 | Approved | Vagus Nerve Stimulation |
| 2025-LHCC-1271 | Implantable Hypoglossal Nerve Stimulation for OSA | 9/2/25 | 10/17/25 | Approved | Implantable Hypoglossal Nerve Stimulation for OSA |
| 2025-LHCC-1274 | Osteogenic Stimulation | 9/2/25 | 10/17/25 | Approved | Osteogenic Stimulation |
| 2025-LHCC-1284 | Preventive Health and Clinical Practice | 9/2/25 | 10/17/25 | Approved | Preventive Health and Clinical Practice |
| 2025-HBL-1311 | Bone Anchored and Bone Conduction Hearing Aids | 9/2/25 | 10/17/25 | Approved | Bone Anchored and Bone Conduction Hearing Aids |
| 2025-LHCC-1412 | Clinical Policy: Clinical Trials | 9/2/25 | 10/17/25 | Approved | Clinical Policy: Clinical Trials |
| 2025-LHCC-1524 | Posterior Tibial Nerve Stimulation for Voiding Dysfunction | 9/2/25 | 10/17/25 | Approved | Posterior Tibial Nerve Stimulation for Voiding Dysfunction |
| 2025-LHCC-1525 | Intradiscal Steroid Injections for Pain Management | 9/2/25 | 10/17/25 | Approved | Intradiscal Steroid Injections for Pain Management |
| 2025-LHCC-1526 | Trigger Point Injections | 9/2/25 | 10/17/25 | Approved | Trigger Point Injections |
| 2025-LHCC-1744 | Phototherapy for Neonatal Hyperbilirubinemia | 9/2/25 | 10/17/25 | Approved | Phototherapy for Neonatal Hyperbilirubinemia |
| 2025-LHCC-2225 | Lantidra (donislecel) Allogeneic Pancreatic Islet Cellular Therapy | 9/2/25 | 10/17/25 | Approved | Lantidra (donislecel) Allogeneic Pancreatic Islet Cellular Therapy |
| 2025-HUM-1548 | Individual Placement and Support (IPS) | 8/5/25 | 9/19/25 | Approved | Individual Placement and Support (IPS) |
| 2025-HUM-1657 | Hospital Bed Clinical Coverage Policy | 8/5/25 | 9/19/25 | Approved | Hospital Bed Clinical Coverage Policy |
| 2025-LHCC-1746 | Total Artificial Heart | 8/5/25 | 9/19/25 | Approved | Total Artificial Heart |
| 2025-LHCC-1840 | Cochlear Implants and Replacements | 8/5/25 | 9/19/25 | Approved | Cochlear Implants and Replacements |
| 2025-LHCC-1945 | Homocysteine Testing | 8/5/25 | 9/19/25 | Approved | Homocysteine Testing |
| 2025-LHCC-2178 | Allogeneic Hematopoietic Progenitor Cell Therapy | 8/5/25 | 9/19/25 | Approved | Allogeneic Hematopoietic Progenitor Cell Therapy |
| 2025-LHCC-2352 | ID Multisystem Lab Testing | 8/5/25 | 9/19/25 | Approved | ID Multisystem Lab Testing |
| 2025-LHCC-2353 | Dermatologic Lab Testing | 8/5/25 | 9/19/25 | Approved | Dermatologic Lab Testing |
| 2025-LHCC-2355 | ID Vector Borne and Tropical Disease Lab Testing | 8/5/25 | 9/19/25 | Approved | ID Vector Borne and Tropical Disease Lab Testing |
| 2025-LHCC-2356 | Primary Care Preventative Lab Testing | 8/5/25 | 9/19/25 | Approved | Primary Care Preventative Lab Testing |
| 2025-LHCC-2357 | ID Genitourinary Lab Testing | 8/5/25 | 9/19/25 | Approved | ID Genitourinary Lab Testing |
| 2025-LHCC-2359 | Gastroenterologic Lab Testing | 8/5/25 | 9/19/25 | Approved | Gastroenterologic Lab Testing |
| 2025-HUM-2528 | Applied Behavioral Analysis DRAFT | 8/5/25 | 9/19/25 | Approved | Applied Behavioral Analysis DRAFT |
| 2025-LHCC-111 | Functional Family Therapy - Child Welfare | 8/5/25 | 9/19/25 | Approved | Functional Family Therapy - Child Welfare |
| 2025-UHC-378 | Surgery of the Shoulder | 8/5/25 | 9/19/25 | Approved | Surgery of the Shoulder |
| 2025-UHC-476 | Cytological Examination of Breast Fluids for Cancer Screening or Diagnosis | 8/5/25 | 9/19/25 | Approved | Cytological Examination of Breast Fluids for Cancer Screening or Diagnosis |
| 2025-UHC-478 | Obstructive and Central Sleep Apnea Treatment | 8/5/25 | 9/19/25 | Approved | Obstructive and Central Sleep Apnea Treatment |
| 2025-LHCC-499 | Retrospective Review For Services Requiring Authorizations | 8/5/25 | 9/19/25 | Approved | Retrospective Review For Services Requiring Authorizations |
| 2025-UHC-562 | Sinus Surgeries and Interventions | 8/5/25 | 9/19/25 | Approved | Sinus Surgeries and Interventions |
| 2025-LHCC-603 | Coordinated System of Care (CSoC) PP | 8/5/25 | 9/19/25 | Approved | Coordinated System of Care (CSoC) PP |
| 2025-UHC-794 | Noncontact Warming Therapy, Ultrasound therapy and Flurescence Imaging for Wounds | 8/5/25 | 9/19/25 | Approved | Noncontact Warming Therapy, Ultrasound therapy and Flurescence Imaging for Wounds |
| 2025-LHCC-1108 | Pediatric Liver Transplant | 8/5/25 | 9/19/25 | Approved | Pediatric Liver Transplant |
| 2025-LHCC-1211 | Reduction Mammoplasty and Gynecomastia Surgery | 8/5/25 | 9/19/25 | Approved | Reduction Mammoplasty and Gynecomastia Surgery |
| 2025-LHCC-1227 | Skin and Soft Tissue Substitutes for Chronic Wounds | 8/5/25 | 9/19/25 | Approved | Skin and Soft Tissue Substitutes for Chronic Wounds |
| 2025-UHC-1393 | Panniculectomy and Body Contouring Procedures | 8/5/25 | 9/19/25 | Approved | Panniculectomy and Body Contouring Procedures |
| 2025-UHC-1400 | Occipital Nerve Injections and Ablations | 8/5/25 | 9/19/25 | Approved | Occipital Nerve Injections and Ablations |
| 2025-LHCC-1452 | Caudal or Interlaminar Epidural Steroid Injections | 8/5/25 | 9/19/25 | Approved | Caudal or Interlaminar Epidural Steroid Injections |
| 2025-LHCC-1454 | Facet Joint Interventions | 8/5/25 | 9/19/25 | Approved | Facet Joint Interventions |
| 2025-LHCC-1456 | Fecal Incontinence Treatments | 8/5/25 | 9/19/25 | Approved | Fecal Incontinence Treatments |
| 2025-LHCC-1457 | Neuromuscular Electrical Stimulation | 8/5/25 | 9/19/25 | Approved | Neuromuscular Electrical Stimulation |
| 2025-LHCC-1506 | Never Paid Events | 8/5/25 | 9/19/25 | Completed | Never Paid Events |
| 2025-HUM-1539 | Crisis Intervention - Follow Up | 8/5/25 | 9/19/25 | Approved | Crisis Intervention - Follow Up |
| 2025-LHCC-1883 | Lumbar Artificial Disc Replacement | 7/15/25 | 8/29/25 | Approved | Lumbar Artificial Disc Replacement |
| 2025-LHCC-1884 | Lumbar Spine Surgery | 7/15/25 | 8/29/25 | Approved | Lumbar Spine Surgery |
| 2025-LHCC-1885 | Knee Arthroscopy | 7/15/25 | 8/29/25 | Approved | Knee Arthroscopy |
| 2025-LHCC-1886 | Sacroiliac Joint Infusion | 7/15/25 | 8/29/25 | Approved | Sacroiliac Joint Infusion |
| 2025-LHCC-1887 | Shoulder Arthroplasty | 7/15/25 | 8/29/25 | Approved | Shoulder Arthroplasty |
| 2025-LHCC-1889 | Shoulder Arthroscopy | 7/15/25 | 8/29/25 | Approved | Shoulder Arthroscopy |
| 2025-ACLA-2133 | Prior Authorization Services List | 7/15/25 | 8/29/25 | Approved | Prior Authorization Services List |
| 2025-UHC-2725 | Respiratory Pathogen Nucleic Acid Detection Testing | 7/15/25 | 8/29/25 | Approved | Respiratory Pathogen Nucleic Acid Detection Testing |
| 2025-UHC-490 | Cardiovascular Disease Risk Tests | 7/15/25 | 8/29/25 | Approved | Cardiovascular Disease Risk Tests |
| 2025-ABH-496 | Community Psychiatric Support and Treatment (CPST) and Psychosocial Rehabilitation (PSR) Services | 7/15/25 | 8/29/25 | Approved | Community Psychiatric Support and Treatment (CPST) and Psychosocial Rehabilitation (PSR) Services |
| 2025-UHC-521 | Gastrointestinal Motility Disorders Diagnosis and Treatment | 7/15/25 | 8/29/25 | Approved | Gastrointestinal Motility Disorders Diagnosis and Treatment |
| 2025-UHC-582 | Cosmetic and Reconstructive Procedures | 7/15/25 | 8/29/25 | Approved | Cosmetic and Reconstructive Procedures |
| 2025-LHCC-682 | Active Procedures in Physical Medicine | 7/15/25 | 8/29/25 | Approved | Active Procedures in Physical Medicine |
| 2025-LHCC-686 | Durable Medical Equipment | 7/15/25 | 8/29/25 | Approved | Durable Medical Equipment |
| 2025-LHCC-689 | Outpatient Habilitative and Rehabilitative Physical and Occupational Therapy | 7/15/25 | 8/29/25 | Approved | Outpatient Habilitative and Rehabilitative Physical and Occupational Therapy |
| 2025-LHCC-691 | Passive Treatment | 7/15/25 | 8/29/25 | Approved | Passive Treatment |
| 2025-LHCC-982 | Outpatient Applied Behavior Analysis Medical Necessity | 7/15/25 | 8/29/25 | Approved | Outpatient Applied Behavior Analysis Medical Necessity |
| 2025-LHCC-1212 | Spinal Cord Stimulation | 7/15/25 | 8/29/25 | Approved | Spinal Cord Stimulation |
| 2025-ABH-1290 | Sinus Procedures | 7/15/25 | 8/29/25 | Approved | Sinus Procedures |
| 2025-UHC-1419 | Carrier Testing for Genetic Diseases | 7/15/25 | 8/29/25 | Approved | Carrier Testing for Genetic Diseases |
| 2025-LHCC-1711 | Sympathetic Nerve Block | 7/15/25 | 8/29/25 | Approved | Sympathetic Nerve Block |
| 2025-LHCC-1750 | Sacroiliac Joint Injections – NIA | 7/15/25 | 8/29/25 | Approved | Sacroiliac Joint Injections – NIA |
| 2025-LHCC-1755 | Paravertebral Facet Joint injections or blocks | 7/15/25 | 8/29/25 | Approved | Paravertebral Facet Joint injections or blocks |
| 2025-LHCC-1756 | Facet Joint Denervation | 7/15/25 | 8/29/25 | Approved | Facet Joint Denervation |
| 2025-LHCC-1878 | Cervical Spine Surgery | 7/15/25 | 8/29/25 | Approved | Cervical Spine Surgery |
| 2025-LHCC-1880 | Hip Arthroplasty | 7/15/25 | 8/29/25 | Approved | Hip Arthroplasty |
| 2025-LHCC-1881 | Hip Arthroscopy | 7/15/25 | 8/29/25 | Approved | Hip Arthroscopy |
| 2025-LHCC-1882 | Knee Arthroplasty | 7/15/25 | 8/29/25 | Approved | Knee Arthroplasty |
Medicaid Managed Care Policies & Procedures Archive (2025)
"Policy or procedure" shall mean a requirement governing the administration of managed care organizations specific to billing guidelines, medical management and utilization review guidelines, case management guidelines, claims processing guidelines and edits, grievance and appeals procedures and process, other guidelines or manuals containing pertinent information related to operations and pre-processing claims, and core benefits and services.
Below are items previously posted for public comment: