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25-1125m Updates to Medicare Clinical Policies - September 2025

Date: 10/29/25

Review retired policies and upcoming changes, effective November 1

The medical policies listed in this update were approved by Centene’s National Medicare Quality Improvement Utilization Management Committee and are effective as of November 2025.

For a complete description of the background, criteria, references, and coding implications for these Medicare medical policies, go to the Medicare Prior Authorization Medical Clinical Policies page.

Apply the Medicare National Coverage Decisions (NCDs) and applicable Local Coverage Decisions (LCDs) local policies for primary coverage guidance.

Retired policies, effective September 2025.

The following policies are no longer active:

Policy number

Policy name

MC.CP.MP.181

Polymerase Chain Reaction Respiratory Viral Panel Testing

MC.CP.MP.184

Home Ventilators

MC.CP.MP.209

GI Pathogen Nucleic Acid Detection Panel Testing

 

Changes to medical policies, effective November 1, 2025

The following are Medicare clinical policies that have been approved for use. The listed policies are effective
November 1, 2025.

Updated Policies

Policy number and title

Summary of changes

MC.CP.MP.249

Allogeneic Hematopoietic Proginator Cell Therapy

  • Annual review.
  • Removed Omisirge specific language from title of policy due to expanding policy.
  • Updated Description of policy to include RegeneCyte and updated the title in the Note referencing the non-Medicare version of the policy.
  • Added Criterion II. to include medically necessary criteria for RegeneCyte…
  • Background updated to include RegeneCyte information to align with updated criteria.
  • Reviewed codes and descriptions.
  • References reviewed and updated.
  • Reviewed by internal specialist.

CC.PP.206

SNF Leveling

  • Annual review.
  • CPT code table removed.

MC.CP.MP.185

Skin Substitutes for
Chronic Wounds of the
Lower Extremities

  • Annual review.
  • Update to background with no impact on criteria.
  • Updated verbiage in Criterion II.A. for clarity.
  • Removed prior Criterion II.B. Updated verbiage in now Criterion II.B.
    for clarity.
  • Removed previous Criterion II.D. Updated verbiage in now Criterion II.C. and D. Removed previous criteria II.G. through I.
  • Updated verbiage in now Criterion II.E. for clarity.
  • Added note regarding documentation requirements under
    Criterion II.
  • Moved HCPCS codes A2009 and Q4304 from table of HCPCS codes that do not support medical necessity to HCPCS codes that do support medical necessity.
  • References reviewed and updated.
  • Reviewed by external specialist.

MC.CP.MP.247

Transplant Service Documentation Requirements

  • Clarified in Description that the policy applies to transplant evaluation and listing requests.
  • Added to the Description and in a note after I.B.11 that transplant admissions require separate authorization.
  • Added requirements for post-transplant follow-up visits and noted in same section regarding other requests.

 

Additional information

If you have questions regarding the information contained in this update, contact the Provider Services Center
and Employer Group Plans, or at 800-929-9224 for Individual 800-641-7761 for Medicare Supplement plans.

Behavioral health providers can call 844-966-0298.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Behavioral Health Providers.



Last Updated: 10/28/2025