Highmark Wholecare Policy Updates

Highmark Wholecare regularly reviews and updates our policies and procedures. To help you know when policies have been amended, we post a Provider Notice to our website one month (30 days) prior to the effective date. You can find these Provider Notices on the first of each month at the following links:

Medicaid Provider Updates

Medicare Provider Updates

Policy Updates Effective February 1, 2025

As a reminder, we have updated or reviewed the following Medical Policies, with changes effective February 1. These updates were previously posted on the Highmark Wholecare provider website January 1, 2025.

Medicaid Policies:

• MP-120-MD-PA Tumor Markers - Corrected Procedure Code table. Added CPT code 86305—advised by PA DHS that the code can be approved on a case-by-case basis.
• MP-112-MD-PA Prescription Digital Therapeutics (e.g., reSET and reSET-O) - No changes to clinical criteria. Updated “Summary of Literature” and “Reference Sources” sections.
• MP-117-MD-PA Clinical Trials - No changes to criteria. Updated “Reference Sources” section.
• MP-102-MD-PA Gastric Electrical Stimulation (GES) - No changes to Experimental/Investigational clinical stance. Updated “Summary of Literature” section.
• MP-077-MD-PA Supervised Exercise Therapy (SET) in the Management of Peripheral Artery Disease - No changes to clinical criteria. Updated “Definitions” and “Reference Sources” sections.
• MP-129-MD-PA Long-Term Acute Care (LTAC) - No changes to clinical criteria. Updated “Reference Sources” section.

Medicare Policies:

• MP-065-MC-PA Assessing Patient’s Suitability for Electrical Nerve Stimulation Therapy (160.7.1 & 160.7) - No changes to clinical criteria. Updated “Reference Sources” section.
• MP-062-MC-PA Fecal Microbiota Transplant - No changes to clinical criteria. Updated “Summary of Literature” and “Reference Sources” sections.