Clinical Policy Annual Review

Fecha: 12/09/25

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

• CP.MP.249 Allogeneic Hematopoietic Progenitor Cell Therapy
• CP.MP.127 Total Artificial Heart
• CP.MP.137 Fecal Incontinence Treatments
• CP.MP.51 Reduction Mammoplasty and Gynecomastia Surgery
• CP.MP.49 PT OT ST
• CP.MP.93 Bone-Anchored Hearing Aid
• CP.MP.185 Skin and Soft Tissue Substitutes for Chronic Wounds
• CP.MP.165 SNRB and TFESI
• CP.MP.166 Sacroiliac Joint Interventions for Pain Management
• CP.MP.92 Acupuncture **RETIRED**