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 November 1, 2025

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

Medicaid Policies:  

• MP-074-MD-PA Oncologic Genetic Testing Panels - No changes to clinical criteria. Updated code description for CPT codes. Removed the following deleted CPT codes. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.    
• MP-001-MD-PA Wearable Cardioverter Defibrillators in the Home Setting - No changes to clinical criteria. Updated ‘Reference Sources’ section.
• MP-050-MD-PA Bronchial Thermoplasty - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
• MP-081-MD-PA Vitamin D Assay Testing - No changes to clinical criteria. Removed and added ICD-10 codes. Updated ‘Reference Sources’ section.
• MP-132-MD-PA Obstetrical Ultrasound - No changes to clinical criteria. Updated ‘Summary of Literature’ section.  
• MP-065-MD-PA Molecular Markers for Fine Needle Aspirates of Thyroid Nodules - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
• MP-018-MD-PA Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
• MP-098-MD-PA Surgical Treatment of Obstructive Sleep Apnea - No changes to experimental/investigational stance. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
• MP-120-MD-PA Tumor Markers - No changes to clinical criteria. Updated ‘Reference Sources’ section.
• MP-059-MD-PA Colorectal Cancer Screening - Policy to be Retired.
• MP-092-MD-PA Upper Gastrointestinal Endoscopy (EGD-esophagogastroduodenoscopy) - Policy to be Retired.

Medicare Policies:

• MP-031-MC-PA Carpal Tunnel Surgery - No changes to clinical criteria. Updated ‘Summary of Literature’ section.
• MP-044-MC-PA Pharmacogenomic Testing for Warfarin Response (NCD 90.1) - No changes to clinical criteria. Updated CMS hyperlink and ‘Reference Sources’ section.
• MP-035-MC-PA Testing for Genetic Disease - No changes to clinical criteria. Updated CMS hyperlinks and ‘Reference Sources’ section.
• MP-088-MC-PA Negative Pressure Wound Therapy (NPWT) Pumps (L33821) - Policy to be Retired.