ProviderMatters

Medical Policy Updates (April 2026)

Posted on March 31, 2026

Please read the following update related to various Health New England programs and changes that may have an impact on your patients and/or your practice. To find policies noted below, please visit healthnewengland.org/Providers/Resources.

If you have any questions about the information in this notice, please contact Health New England Provider Experience at (800) 842-4464, extension 5000. A representative is available Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m.

 

Updates  Effective Date Notes
Medical Policy
Concurrent Review Process Update:

60-Day Provider Notification

 06/01/2026 The following Medical Policies are New:

Cardiac Contractility Modulation for Heart Failure
Line(s) of Business:
Commercial, Medicare, Medicaid
Policy Effective Date: 6/1/2026

 
Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Tremor
Line(s) of Business:
Commercial, Medicare, Medicaid
Policy Effective Date: 6/1/2026

 

The following Medical Policies have Changes:

Breast Surgery
Line(s) of Business:
Commercial, Medicare, Medicaid
Revision Effective Date: 6/1/2026

  • Criteria added for MagTrace® lymphatic trace
  • Codes mapping to MagTrace added i.e. 96372 and A9697
  • No prior authorization required for 96372 and A9697

 

Chimeric Antigen Receptor T-Cell Therapy
Line(s) of Business:
Commercial, Medicare, Medicaid
Revision Effective Date: 6/1/2026

  • Universal Criteria removed
  • References updated

 

Lymphedema – Surgical Treatment
Line(s) of Business:
Commercial, Medicare, Medicaid
Revision Effective Date: 6/1/2026

  • Prophylactic Lymphovenous Bypass (LVB)/Lymphovenous anastomosis (LVA) also called LYMPHA is covered with a prior authorization
  • Coding table updated with 1019T
  • References updated

 

Photochemotherapy (UM460POL)
Line(s) of Business:
Commercial, Medicare, Medicaid
Revision Effective Date: 6/1/2026

  • Updated language around NCD

 

Outpatient Physical and Occupational Therapy
Line(s) of Business:
Commercial, Medicare, Medicaid
Revision Effective Date: 6/1/2026

  • Criteria updated for Home-based PT and OT services (Policy section: VIII)

 

Prostate Procedures (BPH and Prostate Cancer)
Line(s) of Business:
Commercial, Medicare, Medicaid
Revision Effective Date: 6/1/2026

  • Added CPT 51721, 52443, 55881, 55882 (TULSA) as Experimental/Investigational
  • Removed CPT 0421T and added CPT 52597
  • Added CPT 55868 and 55869
  • Removed CPT 0006T and added CPT 55877

 

Renal Denervation for Uncontrolled Hypertension
Line(s) of Business:
Commercial, Medicare, Medicaid
Revision Effective Date: 6/1/2026

  • NCA replaced with NCD 20.40
  • Codes 0935T, C1735 and C1736 added

 

Skin and Soft Tissue Substitutes
Line(s) of Business:
Commercial, Medicare, Medicaid
Policy Effective Date: 6/1/2026

  • Added LCD L39828 and LCA A59712
  • Added Q4398, Q4399, Q4400, Q4401, Q4402, Q4403, Q4404, Q4405, Q4406,
  • Q4407, Q4408, Q4409, Q4410, Q4411, Q4412, Q4413, Q4414, Q4415, Q4416,
  • Q4417, Q4420 to the Experimental/Investigational list
  • Removed Q4100 and added Q4431, Q4432, Q4433
  • Removed DermaMatrix (Q4100) and Dermagraft (Q4106)
  • References updated

 

 

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