Clinical Policy Annual Review

Date: 08/28/26

The following clinical policies have undergone an annual review with some added criteria requirements that may impact the prior authorization process. Please see the revision log within each policy to review the changes.

• Clinical policies: https://www.ambettermeridian.com/provider-resources/clinical-payment-policies
• Upcoming changes: https://www.ambettermeridian.com/provider-resources/clinical-payment-policies/clinical-policy-updates
• HIM.CP.MP.395  Coverage for Gender Affirming Procedures
• CP.MP.182 Short Inpatient Hospital Stay
• CP.BH.300 Biofeedback for Behavioral Disorders
• CP.MP.120 Pediatric Liver Transplant
• CP.MP.150 Phototherapy for Neonatal Hyperbilirubinemia
• CP.MP.54 Hospice Services
• CP.MP.86 Neonatal Abstinence Syndrome Guidelines
• CP.MP.129 Fetal Surgery in Utero for Prenatally Diagnosed Malformations
• CP.MP.164 Caudal or Interlaminar Epidural Steroid Injections
• CP.MP.49 Physical, Occupational, and Speech Therapy Services
• CP.MP.51 Reduction Mammoplasty and Gynecomastia Surgery (RETIRED)