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26-1012m Updates to Medicare Clinical Policies – July 2026

Date: 08/18/26

Review changes to policies and clinical practice guidelines

The medical policies listed in this update were approved by Centene’s National Medicare Quality Improvement Utilization Management Committee and are effective as of July 2026.

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 and applicable Local Coverage Decisions local policies for primary coverage guidance.

Changes to medical policies, effective July 2026

The following are Medicare clinical policies that have been approved for use. The listed policies are effective July 2026.

Updated policies

Policy number and title

Summary of changes

CC.PP.206

SNF Leveling

  • Changed formatting and spelled out numbers in Application section with no clinical significance.
  • In I.D.2.b., spelled out “CVA.”
  • Removed indication for administration of high-cost drug from criteria I.D.2.e. and II.E.2, as well as list of high-cost drugs.
  • Background updated to include additional information regarding skilled nursing services.
  • References reviewed and updated.

MC.CP.MP.249

Allogeneic Hematopoietic Progenitor Cell Therapy

  • Annual review.
  • Coding and descriptions reviewed.
  • References reviewed and updated.
  • Reviewed by internal specialist and external specialist.

MC.CP.MP.247

Transplant Service Documentation Requirements

  • Updated note under criteria section I. stating “… transplant evaluations are effective for six months. After six months have passed, a new authorization …” to “… transplant evaluations are effective for 12 months. After 12 months have passed, a new authorization ...”.

MC.CP.MP.185

Skin and Soft Tissue Substitutes

  • In policy statements IV. to VIII., corrected “non-Medicare health plans” to “Medicare health plans.”
  • Corrected the 03/26 revision log to note that code Q4432 was added to HCPCS code table 3.

 

Need help? Contact us

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by phone or through the Health Net provider portal. Behavioral health providers can call 844-966-0298.

Provider Services

Line of business

Phone number

Email

Medicare (Individual & Employer Group)

(Wellcare By Health Net)

800-929-9224

email

Medicare Supplement

800-641-7761

email

 

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



Last Updated: 08/17/2026