ProviderMatters

Medical Policy Updates (December 2025)

Posted on December 3, 2025

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.

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
Sleep Disordered Breathing Diagnosis and Treatment 02/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
    • For the Medicare line of business, repeat Positive Airway Pressure (PAP) titration study will use InterQual criteria
  • Added jaw expansion prosthesis as experimental/ investigational.
  • Other criteria clarified
Preimplantation Genetic Testing

 

 02/01/2026
  • Line(s) of Business:
    • Commercial
  • Added information regarding PGT-SR to the policy
Cochlear Implants BAHA (Bone-Anchored Hearing Aid) ABI (Auditory Brainstem Implant) Bone-Conduction Hearing Aid

 

 02/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
  • Revision
  • IQ for Cochlear Implantation adopted for Medicaid and Medicare line of business
  • References updated
Tumor Treatment Fields

 

 02/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
  • Revision
  • Minor criteria changes
Transcatheter Tricuspid Valve Interventions

 

 02/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
  • Revision
  • Criteria placed for Commercial and Medicaid line of business with prior authorization
  • Medicare LOB added NCD 20.38 for Transcatheter Edge-to-Edge Repair for Tricuspid Valve Regurgitation (T-TEER)
Transcatheter Mitral Valve Repair

 

 02/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
  • Revision
  • IQ criteria adopted for Medicare line of business
Speech Therapy for Autism Disorders

 

 02/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
  • Revision
  • The following was removed from section I Policy Guidelines:
    • Up to sixteen visits may be authorized initially based on review of the documentation and the member’s plan benefits. Additional visits will be authorized based on medical necessity.
Contact Lens (Therapeutic)

 

 02/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
  • Annual review
  • No changes
Percutaneous Left Atrial Appendage Closure

 

 02/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
  • Revision
  • IQ criteria adopted for Commercial and Medicaid
  • References updated
Speech Language Pathology (SLP) Services 02/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
  • The following was removed:
    • Section II Requirements for Initial Determination: Up to sixteen visits may be authorized initially based on review of the documentation and the member’s plan benefits. Additional visits will be authorized based on medical necessity.
Genetic Testing

 

 02/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
  • New Policy
Renal Denervation for Uncontrolled Hypertension

 

 02/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
  • New Policy
Virtual Cardiac Rehabilitation

 

 02/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
  • New Policy
PANS/PANDAS 02/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
  • Revision
  • Annual Review
  • No changes
Dental Anesthesia and Procedures

 

 01/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
  • Revision
  • Annual review with no changes
  • References updated
Corneal Remodeling for Refractive Errors

 

 01/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
  • Revision
  • Annual review
  • No changes
  • Updated references
Lutetium Therapeutic Radiopharmaceuticals

 

 02/01/2026
  • Line(s) of Business:
    • Commercial, Medicaid, Medicare
  • Revision
  • Annual review
  • No changes
  • Updated references

 

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