Clinical Policy Updates: Effective September 1, 2026

Date: 07/07/26

Thank you for your continued partnership with Health Plan Name. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you of the revision to existing policies Health Plan Name will be implementing effective with Dates of Service starting September 1, 2026. Posted policy on site contains a revision log explaining the updates that occurred in the annual review.

Line of Business: Marketplace; Commercial

Policy Number: CP.MP.242

Policy Name: Pulmonary Function Testing

Policy Description: Pulmonary function tests (PFTs), also known as lung function tests, include a variety of tests to check how well the lungs are working. This policy describes the medical necessity guidelines for pulmonary function testing.

It is the policy of health plans affiliated with Centene Corporation^® that pulmonary function testing (PFT) is medically necessary for members/enrollees aged three years and above when meeting the criteria for one of the following tests:

• Spirometry
• Lung Volume Tests
• Diffusion capacity of the lungs for Carbon monoxide (DLCO) tests
• Lung compliance studies when all other PFTs give equivocal results or results which must be confirmed by additional lung compliance testing
• Pulmonary studies during exercise testing

Policy Number: CP.MP.97

Policy Name: Testing for Select Genitourinary Conditions

Policy Description: Various diagnostic methods are available to identify the etiology of the signs and symptoms of vaginitis. The purpose of this policy is to define medical necessity criteria for the diagnostic evaluation of vaginitis. This policy also defines unspecified amplified DNA probe testing for genitourinary conditions.

Note: Although Trichomonas vaginalis is a common cause of vaginitis, testing for it is not restricted with medical necessity criteria, and, thus, it is not included in the scope of this policy.

Policy Number: CP.MP.181

Policy Name: Polymerase Chain Reaction Respiratory Viral Panel Testing

Policy Description: Medical necessity criteria for multiplex respiratory polymerase chain reaction (PCR) testing.

Note: For criteria applicable to Medicare plans, please see MC.CP.MP.181 Polymerase Chain Reaction Respiratory Viral Panel Testing.

Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.

If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative or call Provider Services at 1-844-518-9505 (TTY 711).

Ambetter from Sunflower Health Plan is underwritten by Celtic Insurance Company, which is a Qualified Health Plan issuer in the Kansas Health Insurance Marketplace. ©2026 Celtic Insurance Company. All rights reserved.