High-Risk Dental/Oral Surgery Criteria — Documentation Required for Alternate Site Care

Baylor Scott & White Health Plan clarifies clinical criteria that justify providing dental/oral surgery care outside a standard office setting for patients with medical comorbidities. The policy lists seven discrete conditions — including severely reduced pulmonary function (e.g., FEV1 <60%), serious bleeding disorders, recent/acute cardiac disease (e.g., MI within 90 days or CHF Class III–IV), immunodeficiency, difficulty regulating endocrine diseases (explicitly citing diabetes and Addison’s), history of anesthesia/sedation reactions, and prior unsuccessful office-based attempts or significant behavioral/functional impairment — any one of which, when documented, supports management outside the office. The focus is on documented clinical risk factors rather than procedure codes or prior authorization instructions. Providers should document at least one listed condition to justify alternate site care for dental/oral surgery.

Preferred CGMs: Dexcom & Freestyle Libre; Other CGMs Non-Preferred

Baylor Scott & White Health Plan designates Dexcom and Freestyle Libre as the plan’s preferred continuous glucose monitors (CGMs); all other CGMs are classified as non-preferred. Non-preferred devices may be approved only if the provider submits clinical rationale explaining why preferred devices are inappropriate, the member meets additional clinical coverage criteria in the plan’s table, and use aligns with the member’s coverage document. The policy ties its CGM coverage framework to LCD 33822 (Glucose Monitors), so applicable CMS/BSWHP local coverage requirements will inform final determinations. Expect non-preferred CGM requests to require extra documentation demonstrating medical necessity and contract consistency.

Tepezza (teprotumumab) Coverage Criteria Consolidation — Mar 2026

Effective March 1, 2026 UnitedHealthcare consolidated and clarified coverage criteria for teprotumumab (Tepezza) for Thyroid Eye Disease (TED). Coverage requires a TED diagnosis with specified severity thresholds: active symptomatic disease plus at least one objective sign (e.g., lid retraction ≥2 mm, moderate/severe soft tissue involvement, proptosis ≥3 mm above race/sex norms, or diplopia) or chronic inactive disease with ≥3 mm increased proptosis or proptosis ≥3 mm above norms. Patients must meet thyroid-status criteria (euthyroid or controlled/mild dysfunction), have prior intolerance/ failure/contraindication to glucocorticoids when applicable, and prescriptions must come from an endocrinologist or ophthalmologist; concurrent biologic immunomodulators are prohibited. Dosing must follow FDA labeling with a lifetime limit of 8 infusions; evidence from RCTs supports proptosis and symptom benefit with manageable safety considerations such as hyperglycemia.

Cigna Update: Enumerated Vitamin D Testing Indications, Limits & Exclusions

Effective 6/15/2026, Cigna’s Vitamin D Testing policy (0526) defines explicit, enumerated medical-necessity indications for total 25(OH)D (CPT 82306/0038U) and for active 1,25(OH)2D (CPT 82652), and sets repeat-testing limits. Total 25(OH)D testing is authorized only for listed conditions (e.g., rickets/osteomalacia, CKD, malabsorption, hyperparathyroidism, granulomatous disease, certain medications, extremes of age, prior deficiency, toxicity, specified genetic disorders), with repeat testing allowed only every 3 months when criteria are met. Active 1,25(OH)2D testing is limited to separate, specific indications (e.g., CKD, phosphate-wasting disorders, oncogenic osteomalacia, granulomatous or inflammatory diseases), and combined billing of both assays is expressly not covered. The policy reiterates that vitamin D testing for general population screening or unlisted indications is not covered; coverage decisions remain subject to plan language and applicable law.

Cigna IP0415: Synarel (nafarelin) Coverage Criteria — Mar 15, 2026

Cigna updated IP0415 (effective 2026-03-15) to define coverage and utilization limits for Synarel (nafarelin acetate) for central precocious puberty and endometriosis. Central precocious puberty coverage requires objective lab confirmation (basal LH ≥0.2 mIU/mL or GnRH stimulation test), onset before age 8 in females or 9 in males, and is approved for 1 year; product-preference rules apply. Endometriosis coverage is for adults ≥18 years for 6 months after failure or contraindication to a contraceptive or progestin (unless prior GnRH agonist/antagonist use), with employer-specific exceptions allowing alternate prior-therapy pathways. Synarel is explicitly not covered for peripheral (GnRH-independent) precocious puberty; employer plans may impose additional step-therapy or product-preference requirements.

Cigna (0158) Updates: Device‑Specific Hypoglossal Nerve Stimulator Criteria, DISE & Pediatric Down Syndrome

Effective 6/15/2026 Cigna updated coverage for FDA‑approved implantable hypoglossal nerve stimulation devices for OSA to include device‑specific medical necessity criteria, explicit DISE requirements, and pediatric Down syndrome indications. Inspire and Genio® System 2.1 have separate age, AHI and BMI thresholds (Inspire adults ≥18: AHI 15–100, BMI ≤40; Genio® ≥22: AHI 15–65, BMI ≤32; Inspire adolescents 13–18 with Down syndrome: AHI >10–<50, BMI ≤95th percentile). Coverage requires documented PAP failure/intolerance (or unwillingness), central+mixed apneas ≤25% of AHI, absence of complete concentric collapse on DISE, and adherence to FDA PMA conditions. Remote replacement of malfunctioning, out‑of‑warranty remotes is covered, while off‑the‑shelf remote batteries are generally not medically necessary; related DISE and implantation CPT codes are listed.

UnitedHealthcare MDC10 updates: MiniMed Instinct added; Mycapssa & subcutaneous biologic wording revised

UnitedHealthcare updated its Endocrinology & Metabolism (Diabetes/Thyroid) coverage guidance with multiple annual-review edits effective 3/1/2026–5/1/2026. The CGM program explicitly adds MiniMed Instinct to the “Continuous glucose monitors, sensors and transmitters (all brands)” medical necessity policy effective 3/1/2026. Mycapssa (octreotide) criteria (effective 4/1/2026) remove prior surgery/radiation/bromocriptine requirements for initiation, add Lanreotide Injection as an example, add a prescriber requirement, clarify reauthorization with an example of positive clinical response, and note injectable somatostatin analogs may require additional benefit/coverage review. Actemra/Tyenne and Orencia wording was clarified to specify subcutaneous formulations and reinforce “not used in combination” language; Invokana was listed as non‑formulary with updated references (5/1/2026).

UnitedHealthcare: Yorvipath (PTH 1-34) Prior Authorization Criteria — Mar 2026

UnitedHealthcare’s March 1, 2026 policy establishes formal prior authorization criteria for Yorvipath (PTH 1-34) for adult hypoparathyroidism, requiring biochemical confirmation before initiation. Initial approval requires albumin-corrected serum calcium ≤ 8.5 mg/dL on two occasions and intact PTH <20 pg/mL (or undetectable) on two occasions, measured by a 2nd/3rd-generation assay; therapy is not approved for acute post‑surgical hypoparathyroidism. Patients must be on adequate supplemental calcium and active vitamin D with specified calcium and 25(OH)D ranges prior to initiation, and initial prescriptions must be written by an endocrinologist or nephrologist. Reauthorization requires documented clinical benefit with serum calcium in the normal range and reduced dependence on conventional therapy (no active vitamin D and ≤600 mg/day calcium).

Cigna IP0739: GLP‑1/GLP‑1‑GIP Coverage Clarified — Dosing, Switching, MASH Criteria

Cigna updated IP0739 (effective 2026-03-01) to clarify coverage for GLP-1 and GLP-1/GIP agents used for weight management and related indications, emphasizing liraglutide (Saxenda/generic), Wegovy (injection and tablets), and Zepbound. The revision details FDA-approved indications, age and BMI thresholds, required behavioral interventions, time-limited initial authorizations, and criteria for continuation/maintenance (including response thresholds such as ≥5% weight loss). Wegovy dosing escalation, maintenance doses, and allowed switches between Wegovy injection and tablet formulations are specified, with timelines for safe transition and tolerability-based delays. MASH coverage requires documented F2–F3 fibrosis by accepted testing modalities and specific metabolic risk factors; concomitant use of multiple GLP-1 or GLP-1/GIP agents is explicitly considered not medically necessary across indications.

Cigna MDC 10 Update: Category III Code Mapping to Diabetes Supplies (0446T–0448T)

Effective April 15, 2026, Cigna’s MDC 10 (Endocrinology & Metabolism — Diabetes/Thyroid) policy 0558 was updated to add related coverage resource links and to map specific Category III CPT codes to those resources. The update explicitly identifies Diabetes Equipment and Supplies as a related policy and maps Category III codes 0446T, 0447T, and 0448T to that policy as medically necessary for certain indications. Multiple other related policies are listed with their own Category III code cross-references, but clinical indications, coverage limits, and benefit language are not included in this excerpt. Use policy 0558 as an index to locate detailed equipment/supply coverage and the clinical criteria in the referenced Diabetes Equipment and Supplies policy.