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Policy Updates

Published Date: 2025-11-18

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 December 1, 2025

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

Medicaid Policies:

MP-138-MD-PA Cardiovascular Disease Laboratory Testing – New Policy
MP-139-MD-PA Lymphoscintigraphy – New Policy
MP-140-MD-PA Pulse Oximetry, Home Use – New Policy
MP-118-MD-PA Experimental/Investigational Services - Removed procedure codes per PA DHS TAG determination.
MP-126-MD-PA Pharmacogenetic Testing - Added coding and Program Exception information per PA DHS guidance. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
MP-070-MD-PA Electrical Bone Growth Stimulators (Noninvasive/Invasive, Spinal, & Ultrasound) - No changes to clinical criteria.
MP-099-MD-PA Electrical Stimulation for Oropharyngeal Dysphagia - No changes to Experimental/Investigational stance.
MP-100-MD-PA Gene Expression and Biomarker Prostate Cancer Testing - No changes to experimental/investigational stance.
MP-101-MD-PA Repetitive Transcranial Magnetic Stimulation - No change to Experimental/Investigational determination.
MP-104-MD-PA Exhaled Nitric Oxide Measurement in the Management of Respiratory Disorders - No changes to experimental/investigational stance.
MP-105-MD-PA Breast Scintimammography - No changes to experimental/investigational stance.
MP-106-MD-PA Dual-Energy X-ray Absorptiometry (DXA) for Vertebral Fracture Assessment - No change to experimental/investigational stance.
MP-109-MD-PA Bronchial Valves - No changes to experimental/investigational stance.
MP-114-MD-PA Cardiac Contractility Modulation (CCM) Therapy - No changes to clinical criteria.
MP-115-MD-PA Concurrent Care - No changes to clinical criteria.
MP-117-MD-PA Clinical Trials - No changes to clinical criteria.
MP-129-MD-PA Long-Term Acute Care (LTAC) - No changes to clinical criteria.
MP-007-MD-PA Hyperbaric Oxygen Therapy (HBOT) - Policy to be Retired.
MP-069-MD-PA Home Oxygen Therapy (HOT) - Policy to be Retired.
MP-084-MD-PA Cochlear Implants - Policy to be Retired.
MP-102-MD-PA Gastric Electrical Stimulation (GES) - Policy to be Retired.
MP-111-MD-PA Endoscopic Ultrasound (EUS) and Endoscopic Retrograde Cholangiopancreatography (ERCP) - Policy to be Retired.

Medicare Policies:

MP-076-MC-PA Biomarkers Overview (L35062) - No changes to clinical criteria.
MP-077-MC-PA Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (NCD 20.35) - No changes to clinical criteria.
MP-098-MC-PA Osteogenic Stimulators (150.2) - Policy to be Retired.