Policy Number

Policy Name

Policy Description

Lines of Business

Effective Date

Revision Log Detail

CM.MP.106

Endometrial Ablation

This policy describes the medical necessity guidelines for an endometrial ablation given the absence of coverage criteria provided by the Centers for Medicare and Medicaid Services (CMS) and the applicable Medicare Advantage Contractors.

Endometrial ablation is a minimally invasive surgical procedure used to treat premenopausal abnormal uterine bleeding. Although this procedure preserves the uterus, endometrial ablation is indicated for those who have no desire for future fertility. The two major classifications of endometrial ablation procedures are first generation resectoscopic techniques and second generation nonresectoscopic methods. Quality of life resulting from reduced bleeding and

amenorrhea may improve following

Medicaid Medicare

6/1/2026

·   Updated contraindication in Criteria I.G.4. regarding intrauterine device for clarity.

·   Removed contraindication of recent pregnancy in Criteria I.G.7.

·   Coding and descriptions reviewed.

·   References reviewed and updated.

·   Reviewed by external specialist.

·   Updated description to note the absence of coverage criteria from CMS and added where criteria are sourced and risk versus benefit information.

Policy

Number

Policy Name

Policy Description

Lines of

Business

Effective

Date

Revision Log Detail

endometrial ablation

procedures.

CC.PP.073

Sepsis Diagnosis

Acute care hospitalizations for sepsis require the most appropriate and most specific level of diagnosis coding. The medical record documentation supporting the diagnosis should be clearly documented by the physician or a licensed independent practitioner, and consistent with current guidelines.

The policy describes the process for pre-and post-pay review to validate correct coding on inpatient claims billed with a sepsis diagnosis but

is not applicable to sepsis screening.

Medicaid Medicare Marketplace

6/1/2026

·   References reviewed and updated. Reviewed codes and descriptions.

·   Clarified in Section I.A. that the Sequential Organ Failure Assessment (SOFA) score is calculated “from the member/enrollee’s baseline.”

·   Under “reimbursement guidelines,” changed language from “registered nurses” reviewing to “clinicians.”

·   Minor rewording for clarity.

CP.BH.124

Attention Deficit Hyperactivity Disorder Assessment and Treatment

Attention deficit hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders in children, with an increasing prevalence of diagnosis in adults. ADHD affects the cognitive, academic, emotional, and social well-being of individuals and can persist throughout life. While there is no single test to diagnose ADHD, a clinical assessment based on defined clinical parameters establishes criteria for diagnosis in children and adults.

Medicaid

8/1/2026

·   Coding changes bring policy into alignment with other payer policies, LCD, LCA, and American Academy of Child and Adolescent Psychiatry (AACAP)

recommendations.

·   Remove the following CPT codes as not payable when only billed with any ICD-10 codes within the following range F90.0 through F90.9 (Attention-deficit hyperactivity disorders):

•   84437 Thyroxine; requiring elution (eg, neonatal)

•   92569 Deleted Code: Acoustic reflex testing; decay

•   96116 Neurobehavioral status exam (clinical assessment of thinking,

reasoning and judgment,

Policy

Number

Policy Name

Policy Description

Lines of

Business

Effective

Date

Revision Log Detail

[eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour

•   96121 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; each additional hour (List separately in addition to code for primary procedure)

·   Add the following CPT codes as not payable when only billed with any ICD-10 codes within the following range: F90.0 through F90.9:

•   92066 Orthoptic training; under supervision of a physician or other qualified health care professional

•   92545 Oscillating tracking test, with recording

•   92546 Sinusoidal vertical axis rotational testing

•   92548 Computerized dynamic posturography sensory organization test

(CDP-SOT), 6 conditions (ie, eyes open, eyes

Policy

Number

Policy Name

Policy Description

Lines of

Business

Effective

Date

Revision Log Detail

closed, visual sway, platform sway, eyes closed platform sway, platform and visual sway), including interpretation and report;

•   96369 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of

subcutaneous infusion site(s).

CP.MP.38

Ultrasound in Pregnancy

This policy outlines the medical necessity criteria for ultrasound use in pregnancy.

Ultrasound is the most common fetal imaging tool used today.

Ultrasound is accurate at determining gestational age, fetal number, viability, and placental location and is necessary for many diagnostic purposes in obstetrics. The determination of the time and type of ultrasound should allow for a specific clinical question(s) to be answered.

Ultrasound exams should be conducted only when indicated and must be appropriately documented.

Marketplace

8/1/2026

·        Coding changes bring policy into alignment with other payer policies.

·        Changes allow payment for 76805 if billed for a second time within a rolling six months [this is the timeframe for the frequency limit that is currently in place for this code] of being billed on a previous claim, if billed by a different TIN than the previous claim with 76805.

·        Add the following ICD-10 codes as payable with CPT code 76811: A93.0, O35.0XX1, O35.0XX2, O35.0XX3, O35.0XX4, O35.0XX5, O35.0XX9, O35.1XX0, O35.1XX1, O35.1XX2, O35.1XX3, O35.1XX4, O35.1XX5, O35.1XX9