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2025 Quarter Four Clinical Policy Review

The following clinical policies have undergone an annual review with some added criteria requirements that may impact the prior authorization process. Please see the revision log within each policy to review the changes:

  • CP.MP.185 Skin and Soft Tissue Substitutes for Chronic Wounds
  • CP.MP.61 IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures
  • CP.MP.248 Facility-based Sleep Studies for Obstructive Sleep Apnea 

The following clinical policies have been adopted:

  • CP.MP.115 Discography
  • CP.MP.116 Lysis of Epidural Lesions
  • CP.MP.144 Mechanical Stretching Devices for Joint Stiffness and Contracture
  • CP.MP.188 Pediatric Oral Function Therapy 
  • CP.MP.70 Proton and Neutron Beam Therapies
  • CP.MP.247 Transplant Service Documentation Requirements
  • CP.MP.249 Omisirge (omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy 
  • CP.MP.250 Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy
  • CP.MP.62 Hyperhidrosis Treatments

These changes go into effect on February 24, 2026. Active clinical policies can be found on our Medical Policies page. The above policies will be available for review after the effective date.

Last Updated: 01/21/2026