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New PoliciesDatopotamab deruxtecan (Datroway®)08.02.4111/3/202511/3/2025This is a New Policy.
New PoliciesZevaskyn™ (prademagene zamikeracel)08.02.4611/3/202511/3/2025This is a New Policy.
New PoliciesZevaskyn™ (prademagene zamikeracel)08.02.4612/1/202511/14/2025This is a New Policy.11/14/2025
Updated PoliciesExperimental/Investigational Services12.01.01br10/1/202511/3/2025Medical Coding
Updated PoliciesImplantable Cardioverter Defibrillators05.00.77f11/3/202511/3/2025Medical Necessity Criteria11/3/2025
Updated PoliciesDurable Medical Equipment (DME) and Consumable Medical Supplies [AmeriHealth Pennsylvania]05.00.21ai10/10/2025 10:00 AM11/10/202511/10/2025Coverage and/or Reimbursement Position
Updated PoliciesErythropoiesis-Stimulating Agents (ESAs)08.00.75q11/17/202511/17/2025Medical Necessity Criteria;Medical Coding
Updated PoliciesHigh-Frequency Chest Wall Oscillation Devices05.00.14s11/17/202511/17/2025Medical Necessity Criteria
Updated PoliciesAdo-Trastuzumab Emtansine (Kadcyla®)08.01.11j11/17/202511/17/2025Medical Necessity Criteria;Medical Coding
Updated PoliciesAllogeneic Processed Thymus Tissue-agdc (Rethymic®)08.01.88b11/17/202511/17/2025Medical Necessity Criteria
Updated PoliciesHigh-Technology Radiology Services (AmeriHealth)09.00.46at11/15/202511/17/2025General Description, Guidelines, or Informational Update
Updated PoliciesPercutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (AmeriHealth)11.02.27l11/15/202511/17/2025General Description, Guidelines, or Informational Update
Updated PoliciesMusculoskeletal Services (AmeriHealth)00.01.66q11/17/202511/17/2025Medical Necessity Criteria
Updated PoliciesSleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies07.03.05ab11/15/202511/17/2025Medical Necessity Criteria;General Description, Guidelines, or Informational Update
Updated PoliciesPemetrexed (Pemfexy™)08.00.87o11/17/202511/17/2025Medical Necessity Criteria;Medical Coding
Updated PoliciesPertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo®)08.01.72b11/17/202511/17/2025Medical Necessity Criteria;Medical Coding
Updated PoliciesCarfilzomib (Kyprolis®)08.01.05m11/17/202511/17/2025Medical Necessity Criteria;Medical Coding
Updated PoliciesLanreotide (Somatuline® Depot)08.01.40h11/17/202511/17/2025Medical Necessity Criteria;Medical Coding
Updated PoliciesBioimpedance for the Detection of Lymphedema07.06.03c11/17/202511/17/2025Coverage and/or Reimbursement Position;Medical Necessity Criteria;Medical Coding;General Description, Guidelines, or Informational Update
Updated PoliciesPhotodynamic Therapy (PDT) Using Verteporfin (Visudyne®)07.13.05m11/17/202511/17/2025Medical Coding;General Description, Guidelines, or Informational Update
Updated PoliciesLoncastuximab tesirine-lpyl (Zynlonta®)08.00.59d11/17/202511/17/2025Medical Necessity Criteria;General Description, Guidelines, or Informational Update
Updated PoliciesMusculoskeletal Services (AmeriHealth)00.01.66q11/17/202511/18/2025Medical Necessity Criteria11/18/2025
Updated PoliciesMusculoskeletal Services (AmeriHealth)00.01.66q11/17/202511/19/2025Medical Necessity Criteria
Reissue PoliciesShort-term Interstitial Continuous Glucose Monitoring Systems (CGMS)05.00.24s11/1/202311/12/202511/12/2025
Reissue PoliciesDrugs, Biologics, or Gene Therapies with an Accelerated Approval08.02.351/1/202511/12/202511/12/2025
Reissue PoliciesProcedures for the Treatment of Acne11.08.29e10/1/201611/26/202511/26/2025
Reissue PoliciesPain Management of Peripheral Nerves by Injection07.03.2712/27/202111/26/202511/26/2025
Reissue PoliciesInsulin Pumps and Long-Term Interstitial Continuous Glucose Monitoring Systems05.00.79l4/1/202511/26/202511/26/2025
Reissue PoliciesAlglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ), Cipaglucosidase alfa-atga (Pombiliti™ )08.00.72l4/22/202411/26/202511/26/2025
Reissue PoliciesOutpatient Short-Term Rehabilitation Services Included in Capitation00.03.03i9/25/202311/26/202511/26/2025
Reissue PoliciesCobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing06.02.54c10/1/202211/26/202511/26/2025
Reissue PoliciesRepair and Replacement of Durable Medical Equipment (DME) and Prosthetic Devices05.00.44t10/1/202511/26/202511/26/2025
Reissue PoliciesBilling for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus00.10.39q1/1/202511/26/202511/26/2025
Reissue PoliciesBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use08.00.66w1/1/202511/26/202511/26/2025
Reissue PoliciesRisankizumab-rzaa (Skyrizi®) for Intravenous Use 08.01.95c10/21/202411/26/202511/26/2025
Reissue PoliciesObstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product00.03.10f9/25/202311/26/202511/26/2025
Reissue PoliciesTesting Serum Vitamin D Levels06.02.51d10/1/202011/26/202511/26/2025
Reissue PoliciesEnzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase®, Vimizim®, Naglazyme®, Mepsevii™, etc.)08.00.70e6/3/201911/26/202511/26/2025
Reissue PoliciesTebentafusp-tebn (Kimmtrak®)08.01.85b10/1/202211/26/202511/26/2025
Reissue PoliciesVedolizumab (Entyvio®) for Injection for Intravenous Use08.01.18i9/9/202411/26/202511/26/2025
Reissue PoliciesEnzyme Replacement Therapy for Adenosine Deaminase Severe Combined Immune Deficiency (e.g., elapegademase-lvlr [Revcovi])08.01.26d8/30/202111/26/202511/26/2025
Reissue PoliciesTelemedicine and Telehealth Services for AmeriHealth New Jersey Members00.10.42h7/1/202511/26/202511/26/2025
Reissue PoliciesServices Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers00.10.01al1/1/202511/26/202511/26/2025
Reissue PoliciesOutpatient Diabetes Education and Self-Management Training12.05.01j10/26/202011/26/202511/26/2025
Reissue PoliciesRoutine Costs Associated with Qualifying Clinical Trials07.00.20g7/5/202111/26/202511/26/2025
Reissue PoliciesGenetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations (AmeriHealth Administrators)06.02.06s1/1/202511/26/202511/26/2025
Coding UpdateIntravenous Infliximab and Related Biosimilars08.00.34w10/1/202511/17/202511/17/2025
Coding UpdateIntravenous Infliximab and Related Biosimilars08.00.34w10/1/202511/17/2025
Coding UpdateBotulinum Toxin Agents08.00.26ae10/1/202511/25/2025