6/13/2024

Highmark Wholecare 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 July 1, 2024

As a reminder, we have updated or reviewed the following Medical Policies, with changes effective July 1. These updates were previously posted on the Highmark Wholecare provider website June 1, 2024.

 

Medicaid Policies:

  • MP-107-MD-PA Treatment of the Prostate - Changed policy title from “Prostatic Urethral Lift” to “Treatment of the Prostate.” Added coverage guidance under ‘Procedures’ section for various procedures. Updated coverage guidance for PUL. Added various CPT codes, ICD-10 codes, and Noncovered Procedure codes. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
  • MP-057-MD-PA Cardiac Rehabilitation, Phase II Outpatient - Updated ‘Procedure’ section with additional indications for when cardiac rehabilitation is not medically necessary and additional contraindications. Added indications for home cardiac rehabilitation. Added CPT code 93797 to the ‘Coding Requirements’ section.
  • MP-052-MD-PA Breast Reconstructive Surgery - Added Mastectomy, Mastectomy for Fibrocystic Breast, and Nipple Sparing Mastectomy (NSM) guidance under ‘Procedures’ section. Added the various mastectomy related CPT codes. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
  • MP-113-MD-PA Gastrointestinal Pathogen Assays - No changes to clinical criteria. Added CPT code 0369U. Revised ‘Coding Requirements’ section formatting. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.

Medicare Policies:

 

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