2025 Quarter 3 Clinical Policy Review Updates
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.166 – Sacroiliac Joint Interventions for Pain Management
- MI.CP.MP.528 – Out of Network Services
The following clinical policies have been adopted:
- CP.MP.243 – Implantable Loop Recorder
- CP.MP.176 – Outpatient Cardiac Rehabilitation
- CP.MP.114 – Disc Decompression Procedures
- CP.MP.203 – Diaphragmatic Phrenic Nerve Stimulation
- CP.MP.91 – Obstetrical Home Care Programs
- MI.CP.MP.49 – Physical, Occupational, and Speech Therapy Services
- MI.CP.PMN.159 – Immunomodulators Quantity Limit Exceptions
The following clinical policies have been retired:
- CP.MP.49 – Physical, Occupational, and Speech Therapy Services
- CP.MP.38 – Ultrasound in Pregnancy
- CP.MP.98 – Urodynamic Testing
- CP.MP.100 – Allergy Testing and Therapy
- CP.MP.106 – Endometrial Ablation
- CP.MP.121 – Homocysteine Testing
- CP.MP.153 – Helicobacter Pylori Serology Testing
- CP.MP.152 – 25-hydroxyvitamin D Testing in Children and Adolescents
- CP.MP.154 – Thyroid Hormones and Insulin Testing in Pediatrics
- CP.MP.155 – EEG in the Evaluation of Headache
- CP.MP.242 – Pulmonary Function Testing
- CP.MP.49 – Physical, Occupational, and Speech Therapy Services
These changes go into effect on November 17, 2025. Clinical policies are located on our Clinical and Payment Policy Page.