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Medical and drug policies

The UnitedHealthcare Community Plan for Louisiana is no longer active as of Apr. 1, 2026.

 

The medical policies and medical benefit drug policies for UnitedHealthcare Community Plan of Louisiana are listed below.

 

View the MCG criteria for the top outpatient procedures and admission diagnoses.

Policies

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Abnormal Uterine Bleeding and Uterine Fibroids (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses the use of levonorgestrel-releasing intrauterine devices (LNG-IUD), uterine artery embolization (UAE), magnetic resonance-guided focused ultrasound ablation (MRgFUS), and ultrasound-guided radiofrequency ablation. Applicable Procedure Codes: 0071T, 0072T, 37243, 58563, J7296, J7297, J7298, J7301, J7306, S4981.

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Adzynma (ADAMTS13, Recombinant-Krhn) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 07.01.2025-03.31.2026 – This policy addresses the use of Adzynma (ADAMTS13, recombinant-krhn) for the treatment of congenital thrombotic thrombocytopenic purpura (cTTP). Applicable Procedure Code: J7171.

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Airway Clearance Devices (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 11.01.2025-03.31.2026 – This policy addresses airway clearance devices, such as high-frequency chest wall oscillation systems, acoustical or mechanical percussor, positive expiratory pressure and aerosol drug delivery system combination device, and intrapulmonary percussive ventilation (IPV) devices. Applicable Procedure Codes: A7021, A7025, A7026, E0469, E0481, E0483.

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Alpha1-Proteinase Inhibitors (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 11.01.2025-03.31.2026 – This policy addresses alpha1-proteinase inhibitors (Aralast NP™, Glassia™, Prolastin®-C, and Zemaira®) for chronic augmentation and maintenance therapy of emphysema due to congenital deficiency of alpha1-proteinase inhibitor (A1-PI)/alpha1-antitrypsin (AAT) deficiency. Applicable Procedure Codes: J0256, J0257.

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Ambulance Services (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 10.01.2025-03.31.2026 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services. Applicable Procedure Codes: A0225, A0380, A0382, A0384, A0390, A0392, A0394, A0396, A0398, A0420, A0422, A0424, A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436, A0998, S0207, S0208, S9960, S9961, T2007.

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Apheresis (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.

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Autologous Cellular Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses autologous cellular therapy. Applicable Procedures Codes: 0263T, 0264T, 0265T, 0489T, 0490T, 0565T, 0566T, 0717T, 0718T, 0999T, 1000T, 1001T.

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Bariatric Surgery (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 04.01.2025-03.31.2026 – This policy addresses bariatric surgical procedures, including gastric bypass, gastric banding, sleeve gastrectomy, biliopancreatic bypass, and biliopancreatic diversion with duodenal switch. Applicable Procedure Codes: 0813T, 43290, 43291, 43644, 43645, 43647, 43648, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846, 43847, 43848, 43860, 43865, 43881, 43882, 43886, 43887, 43888, 43999, 64590, 64595, 64999.

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Beds and Mattresses (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 05.01.2025-03.31.2026 – This policy addresses hospital beds, mattresses, and accessories. Applicable Procedure Codes: E0193, E0194, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0271, E0272, E0277, E0280, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0305, E0310, E0316, E0328, E0329, E0373, E0910, E0911, E1399.

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Botulinum Toxins A and B (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 10.01.2025-03.31.2026 – This policy addresses the use of botulinum toxin types A and B, including Dysport® (abobotulinumtoxinA), Xeomin® (incobotulinumtoxinA), Botox® (onabotulinumtoxinA), and Myobloc® (rimabotulinumtoxinB). Applicable Procedure Codes: J0585, J0586, J0587, J0588, J0589.

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Breast Imaging for Screening and Diagnosing Cancer (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses breast imaging, including digital mammography, magnetic resonance imaging (MRI), ultrasound, automated breast ultrasound system, computer-aided detection (CAD), computer-aided tactile breast imaging, electrical impedance scanning (EIS), magnetic resonance elastography (MRE), and molecular breast imaging. Applicable Procedure Codes: 0422T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 76376, 76377, 76391, 76498, 77046, 77047, 77048, 77049, S8080.

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Breast Reconstruction (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 11.01.2025-03.31.2026 – This policy addresses breast reconstruction post-mastectomy and for the treatment of Poland syndrome, removal of breast implants, and breast repair and reconstruction not post mastectomy. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15771, 15772, 15777, 19316, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, 19499, L8600, S2066, S2067, S2068, S8950.

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Breast Reduction Surgery (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.

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Brineura® (Cerliponase Alfa) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses the use of Brineura® (cerliponase alfa) in pediatric patients with late infantile neuronal ceroid lipofuscinosis (LINCL). Applicable Procedure Code: J0567.

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Brow Ptosis and Eyelid Repair (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 12.01.2025-03.31.2026 – This policy addresses upper and lower eyelid blepharoplasty, upper eyelid blepharoptosis repair, brow ptosis, eyelid surgery with an anophthalmic socket, ectropion or punctal eversion, entropion, lid retraction surgery, canthoplasty/canthopexy, and repair of floppy eyelid syndrome (FES). Applicable Procedure Codes: 15820, 15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67912, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950, 67961, 67966.

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Cardiovascular Disease Risk Tests (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 11.01.2025-03.31.2026 – This policy addresses arterial compliance testing using waveform analysis, carotid intima-media thickness (CIMT) measurement, advanced lipoprotein analysis, endothelial function assessment, and tests for lipoprotein-associated phospholipase A2 (Lp-PLA2) enzyme, other human A2 phospholipases, and long-chain omega-3 fatty acids. Applicable Procedure Codes: 0019M, 0052U, 0308U, 0309U, 0377U, 0415U, 0541U, 83695, 83698, 83701, 83704, 93050, 93799, 93895, 93998.

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Carrier Testing Panels for Genetic Diseases (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 10.01.2025-03.31.2026 – This policy addresses the Ashkenazi Jewish carrier screening and expanded carrier screening panel testing. Applicable Procedure Codes: 0400U, 81412, 81443, 81479.

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Catheter Ablation for Atrial Fibrillation (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses catheter ablation for atrial fibrillation. Applicable Procedure Codes: 93653, 93655, 93656, 93657.

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Chelation Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 09.01.2025-03.31.2026 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J3520, J8499, M0300, S9355.

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Chemotherapy Observation or Inpatient Hospitalization (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses chemotherapy observation or overnight (inpatient) stay.

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Cochlear Implants (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 09.01.2025-03.31.2026 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.

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Cognitive Rehabilitation and Coma Stimulation (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses cognitive rehabilitation and coma stimulation. Applicable Procedure Codes: 97129, 97130, S9056.

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Collagen Crosslinks and Biochemical Markers of Bone Turnover (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.

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Complement Inhibitors (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses the use of Bkemv™ (eculizumab-aeeb), Epysqli® (eculizumab-aagh), PiaSky® (crovalimab-akkz), Soliris® (eculizumab), and Ultomiris® (ravulizumab-cwvz). Applicable Procedure Codes: J1299, J1303, J1307, Q5151, Q5152.

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Computer-Assisted Surgical Navigation for Musculoskeletal Procedures (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2025-03.31.2026 – This policy addresses computer-assisted surgical navigation for musculoskeletal procedures and the use of intra-operative kinetic balance sensor for implant stability during knee replacement arthroplasty. Applicable Procedure Codes: 0054T, 0055T, 20985, 27599.

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Cosmetic and Reconstructive Procedures (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 12.01.2025-03.31.2026 – This policy addresses cosmetic and reconstructive procedures.

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Crysvita® (Burosumab-Twza) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 05.01.2025-03.31.2026 – This policy addresses the use of Crysvita® (burosumab-twza) for the treatment of X-linked hypophosphatemia (XLH) and Fibroblast Growth Factor 23 (FGF23)-related hypophosphatemia in tumor-induced osteomalacia (TIO). Applicable Procedure Code: J0584.

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Cytological Examination of Breast Fluids for Cancer Screening or Diagnosis (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 11.01.2025-03.31.2026 – This policy addresses breast ductal lavage, breast ductal fluid aspiration and cytology, and fiberoptic ductoscopy with or without ductal lavage. Applicable Procedure Code: 19499.

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Deep Brain and Cortical Stimulation (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 05.01.2025-03.31.2026 – This policy addresses deep brain stimulation and responsive cortical stimulation. Applicable Procedure Codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, 61889, 61891, 64999, L8679, L8680, L8682, L8685, L8686, L8687, L8688.

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Denosumab (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 12.01.2025-03.31.2026 – This policy addresses the use of denosumab (Jubbonti®, Osenvelt®, Prolia®, Stoboclo®, Wyost®, and Xgeva®). Applicable Procedure Codes: J0897, Q5136, Q5157.

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Discogenic Pain Treatment (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses thermal intradiscal procedures (TIPs) and percutaneous discectomy and decompression procedures for treating discogenic pain, and annulus fibrosus repair following spinal surgery. Applicable Procedure Codes: 0627T, 0628T, 0629T, 0630T, 22526, 22527, 22899, 63032, S2348.

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Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses durable medical equipment (DME), orthotics, medical supplies, and repairs/replacements.

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Early Periodic Screening, Diagnostics, and Treatment: Personal Care Services (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 09.01.2025-03.31.2026 – This policy addresses early periodic screening, diagnosis, and treatment (EPSDT) for personal care services (PCS). Applicable Procedure Code: T1019.

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Edaravone (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 07.01.2025-03.31.2026 – This policy addresses the use of edaravone for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1301.

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Elective Inpatient Services (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses planned elective inpatient admission for certain surgeries or procedures.

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Electric Tumor Treatment Field Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: A4555, E0766, E0767.

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Electrical and Ultrasonic Bone Growth Stimulators (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses electrical and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20974, 20975, 20979, E0747, E0748, E0749, E0760.

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Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 07.01.2025-03.31.2026 – This policy addresses electrical stimulation for the treatment of pain and muscle rehabilitation, including transcutaneous electrical nerve stimulator (TENS), functional electrical stimulation (FES), and neuromuscular electrical stimulation (NMES). Applicable Procedure Codes: 0278T, 0720T, 0783T, 63650, 63655, 63663, 63664, 63685, 64555, 64596, 64597, 64598, 64999, A4438, A4543, A4544, A4556, A4557, A4593, A4594, A4595, E0720, E0721, E0730, E0731, E0743, E0744, E0745, E0764, E0770, E1399, L8678, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.

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Electromagnetic Therapy for Wounds (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 05.01.2025-03.31.2026 – This policy addresses electromagnetic therapy for wounds. Applicable Procedure Codes: E0769, G0295, G0329.

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Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 08.01.2025-03.31.2026 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.

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Encelto™ (Revakinagene Taroretcel-Lwey) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 12.01.2025-03.31.2026 – This policy addresses the use of Encelto™ (revakinagene taroretcel-lwey) for the treatment of adults with idiopathic macular telangiectasia type 2 (MacTel). Applicable Procedure Code: J3403.

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Enjaymo® (Sutimlimab-Jome) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses the use of Enjaymo® (sutimlimab-jome) for the treatment of cold agglutinin disease (CAD). Applicable Procedure Code: J1302.

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Enteral Nutrition (Oral and Tube Feeding) (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses enteral nutrition. Applicable Procedure Codes: B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9432, S9433, S9434, S9435.

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Epidural Steroid Injections (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 09.01.2025-03.31.2026 – This policy addresses epidural steroid injections for spinal pain. Applicable Procedure Codes: 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484.

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Erythropoiesis-Stimulating Agents (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 04.01.2025-03.31.2026 – This policy addresses the use of erythropoiesis-stimulating agents (ESAs), including Aranesp® (darbepoetin alfa), Epogen® (epoetin alfa), Mircera® (methoxy polyethylene glycol-epoetin beta [MPG-epoetin beta]), Procrit® (epoetin alfa), and Retacrit™ (epoetin alfa). Applicable Procedure Codes: J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106.

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Evenity® (Romosozumab-Aqqg) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 12.01.2025-03.31.2026 – This policy addresses the use of Evenity® (romosozumab-aqqg) for the treatment of osteoporosis in postmenopausal patients at high risk for fracture. Applicable Procedure Code: J3111.

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Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue conditions. Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 0864T, 28890.

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Facet Joint and Medial Branch Block Injections for Spinal Pain (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 07.01.2025-03.31.2026 – This policy addresses facet joint injections/medial branch blocks for spinal pain. Applicable Procedure Codes: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 64490, 64491, 64492, 64493, 64494, 64495.

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FcRn Blockers (Rystiggo®, Vyvgart®, & Vyvgart Hytrulo®) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses the use of Rystiggo®, Vyvgart®, and Vyvgart Hytrulo® for the treatment of myasthenia gravis and Vyvgart Hytrulo® for the treatment of chronic inflammatory demyelinating polyneuropathy (CIDP). Applicable Procedure Codes: J9256, J9332, J9333, J9334.

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FDA Cleared or Approved Companion Diagnostic Testing (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses companion diagnostic testing for oncology indications. Applicable Procedure Codes: 0022U, 0037U, 0179U, 0239U, 0242U, 0473U, 0543U, 81445, 81449, 81450, 81451, 81455, 81456, 81479, 81599.

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Gamifant® (Emapalumab-Lzsg) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses the use of Gamifant® (emapalumab-lzsg) for the treatment of primary and secondary hemophagocytic lymphohistiocytosis (HLH). Applicable Procedure Code: J9210.

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Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 11.01.2025-03.31.2026 – This policy addresses gastric electrical stimulation therapy; manometry, sensation, tone, and compliance testing; defecography; and electrogastrography/electroenterography. Applicable Procedure Codes: 0779T, 0868T, 43647, 43648, 43881, 43882, 64590, 64595, 72195, 72196, 72197, 74270, 76496, 91117, 91120, 91122, 91132, 91133, A9286, A9900, A9999, E1399.

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Genetic Testing for Cardiac Disease (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 0237U, 0401U, 0439U, 0440U, 0466U, 81410, 81411, 81413, 81414, 81439, 81479, 81493.

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Genetic Testing for Hereditary Cancer (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses hereditary breast and ovarian cancer (BRCA1, BRCA2) testing and multi-gene hereditary cancer panel testing. Applicable Procedure Codes: 0101U, 0102U, 0103U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0138U, 0162U, 0238U, 0474U, 0475U, 81162, 81163, 81164, 81432, 81435, 81437, 81441, 81479.

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Glaucoma Surgical Treatments (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses glaucoma drainage devices/stents, canaloplasty, and gonioscopy-assisted transluminal trabeculotomy. Applicable Procedure Codes: 0253T, 0449T, 0450T, 0474T, 0621T, 0622T, 0671T, 0730T, 1012T, 65820, 65855, 66174, 66175, 66179, 66180, 66183, 66710, 66711, 66761, 66762, 66989, 66991, L8612.

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Gynecomastia Surgery (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 09.01.2025-03.31.2026 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.

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Hearing Aids and Devices Including Wearable, Bone-Anchored, and Semi-Implantable (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 08.01.2025-03.31.2026 – This policy addresses wearable air conduction, bone-anchored, semi-implantable hearing aids (SEHA), intraoral bone conduction, and laser or light based hearing aids, and totally implanted middle ear hearing systems.

"0951T, 0952T, 0953T, 0954T, 0955T, 69710, 69714, 69716, 69717, 69719, 69729, 69730, 69799, 92590, 92591, 92592, 92593, 92594, 92595, L8690, L8691, L8692, L8693, L8694, S0618, S2230, V5010, V5011, V5014, V5020, V5030, V5040, V5050, V5060, V5070, V5080, V5095, V5100, V5120, V5130, V5140, V5150, V5171, V5172, V5181, V5190, V5211, V5212, V5213, V5214, V5215, V5221, V5230, V5242, V5243, V5244, V5245, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5262, V5263, V5264, V5265, V5267, V5275, V5298.",
Home Health, Skilled, and Custodial Care Services (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses home health, skilled, and custodial care services.

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Home Traction Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 05.01.2025-03.31.2026 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.

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Hospital Services: Observation and Inpatient (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses hospital services for observation versus inpatient level of care.

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Hysterectomy (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses hysterectomy. Applicable Procedure Codes: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573.

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Implantable Loop Recorders and Wearable Heart Rhythm Monitors (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 07.01.2025-03.31.2026 – This policy addresses implantable loop recorders and wearable heart rhythm monitors/cardiac self-monitoring devices. Applicable Procedure Codes: 0650T, 0902T, 33285, 33286, 93285, 93291, 93297, 93298, 93799, E0616, E1399.

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Implanted Electrical Stimulator for the Spinal Cord (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses implanted electrical stimulator for spinal cord. Applicable Procedure Codes: 63650, 63655, 63685, 63688, L8679, L8680, L8682, L8685, L8686, L8687, L8688, L8695.

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Inhaled Nitric Oxide Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses the use of inhaled nitric oxide (iNO) for treating term or near-term infants with hypoxic respiratory failure or echocardiographic evidence of persistent pulmonary hypertension of the newborn (PPHN). Applicable Procedure Code: 94799.

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Injectable Dermal Fillers and Bulking Agents (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses dermal filler injections and injectable bulking agents. Applicable Procedure Codes: 31570, 31571, 31574, G0429, L8607, Q2026, Q2028.

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Intensity-Modulated Radiation Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses the use of intensity-modulated radiation therapy (IMRT). Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6001, G6002, G6015, G6016, G6017.

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Interspinous Fusion and Decompression Devices (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses interspinous bony fusion devices and decompression systems. Applicable Procedure Codes: 22853, 22854, 22859, 22867, 22868, 22869, 22870, 22899.

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Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses the use of intravenous enzyme replacement drug products for the treatment of Gaucher disease, including Cerezyme® (imiglucerase), Elelyso® (taliglucerase), and VPRIV® (velaglucerase). Applicable Procedure Codes: J1786, J3060, J3385.

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Intravenous Iron Replacement Therapy (Feraheme®, Injectafer®, & Monoferric®) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses the use of intravenous iron replacement therapy with Feraheme® (ferumoxytol), Injectafer® (ferric carboxymaltose), and Monoferric® (ferric derisomaltose) for the treatment of iron deficiency anemia (IDA) with and without chronic kidney disease (CKD). Applicable Procedure Codes: J1437, J1439, Q0138, Q0139.

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Kebilidi™ (Eladocagene Exuparvovec-Tneq) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 11.01.2025-03.31.2026 – This policy addresses the use of Korsuva (difelikefalin) for the treatment of moderate-to-severe pruritus associated with chronic kidney disease in adults undergoing hemodialysis. Applicable Procedure Code: J0879.

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Korsuva® (Difelikefalin) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 07.01.2025-03.31.2026 – This policy addresses the use of Korsuva® (difelikefalin) for the treatment of moderate-to-severe pruritus associated with chronic kidney disease in adults undergoing hemodialysis. Applicable Procedure Code: J0879.

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Krystexxa® (Pegloticase) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 11.01.2025-03.31.2026 – This policy addresses the use of Krystexxa® (pegloticase) for treatment of chronic gout refractory to conventional therapy. Applicable Procedure Code: J2507.

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Light and Laser Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses light and laser therapy, including light phototherapy, photodynamic therapy, intense pulsed light, pulsed dye laser, and laser hair removal. Applicable Procedure Codes: 0479T, 0480T, 17106, 17107, 17108, 17999.

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Liposuction for Lipedema (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses liposuction for lipedema when used to treat functional impairment. Applicable Procedure Codes: 15877, 15878, 15879.

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Lower Extremity Prosthetics (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 11.01.2025-03.31.2026 – This policy addresses lower extremity prosthetics.

"L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5400, L5410, L5420, L5430, L5450, L5460, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5615, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5657, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5827 L5828, L5830, L5840, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5926, L5930, L5940, L5950, L5960, L5961, L5962, L5964, L5966, L5968, L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5991, L5999, L7367, L7368, L7600, L7700, L8400, L8410, L8417, L8420, L8430, L8440, L8460, L8470, L8480.",
Luxturna® (Voretigene Neparvovec-Rzyl) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 11.01.2024-03.31.2026 – This policy addresses the use of Luxturna® (voretigene neparvovec-rzyl) for the treatment of inherited retinal dystrophies (IRD) caused by mutations in the retinal pigment epithelium-specific protein 65kDa (RPE65) gene. Applicable Procedure Code: J3398.

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Mandatory Medicaid Coverage of Routine Patient Costs in Qualifying Clinical Trials (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses covered routine patient costs during qualified clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.

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Manipulation Under Anesthesia (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27860, D7830.

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Manipulative Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 09.01.2025-03.31.2026 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.

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Maximum Dosage and Frequency (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses the maximum dosage per administration and dosing frequency for certain medications administered by a medical professional.

"C9151, J0129, J0177, J0178, J0179, J0222, J0225, J0517, J0585, J0586, J0587, J0588, J0589, J0638, J0717, J0897, J1071, J1073, J1299. J1300, J1301, J1303, J1304, J1306, J1307, J1449, J1602, J1628, J1745, J1747, J2182, J2327, J2350, J2356, J2357, J2506, J2507, J2777, J2778, J2779, J2786, J3032, J3121, J3145, J3245, J3262, J3357, J3358, J3380, J3489, J7170, J9022, J9023, J9035, J9038, J9119, J9173, J9228, J9271, J9299, J9311, J9312, J9332, J9333, J9334, J9355, Q5099, Q5100, Q5103, Q5104, Q5107, Q5108, Q5111, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119, Q5120, Q5121, Q5123, Q5124, Q5126, Q5127, Q5128, Q5129, Q5130, Q5133, Q5135, Q5136, Q5137, Q5138, Q5147, Q9996, Q9997, Q9998, Q9999.",
Mechanical Stretching Devices (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses the use of low-load prolonged-duration stretch devices, static progressive (SP) stretch splint devices, and patient actuated serial stretch (PASS) devices. Applicable Procedure Codes: E1399, E1800, E1801, E1802, E1803, E1804, E1805, E1806, E1807, E1808, E1810, E1811, E1812, E1813, E1814, E1815, E1816, E1818, E1822, E1823, E1825, E1826, E1827, E1828, E1829, E1830, E1832, E1831, E1840, E1841.

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Medical Therapies for Enzyme Deficiencies (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 10.01.2025-03.31.2026 – This policy addresses drug products used as medical therapies for enzyme deficiency. Applicable Procedure Codes: C9399, J0180, J0217, J0218, J0219, J0221, J1203, J2508, J2840, J3590.

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Minimally Invasive Procedures for Gastric and Esophageal Diseases (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2025-03.31.2026 – This policy addresses minimally invasive procedures/devices for treating gastric and esophageal diseases. Applicable Procedure Codes: 43210, 43257, 43284, 43289, 43497, 43499, 43999.

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Minimally Invasive Spine Surgery Procedures (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses minimally invasive spine surgery procedures. Applicable Procedure Codes: 0200T, 0201T, 0275T, 22586, 22630, 22899, 62287, 62380, G0276.

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Molecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment Decisions (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses molecular oncology testing for hematologic cancer. Applicable Procedure Codes: 0017M, 0050U, 0120U, 0171U, 0298U, 0299U, 0300U, 0331U, 0364U, 0413U, 0485U, 0560U, 0561U, 81195, 81450, 81451, 81455, 81456, 81479, 81599.

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Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment Decisions (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses molecular oncology testing for solid tumor cancers, including breast cancer, lung cancer, prostate cancer, thyroid cancer, hematological cancer, lung cancer, and uveal melanoma.

"0005U, 0011M, 0012M, 0013M, 0016M, 0020M 0018U, 0019U, 0022U, 0026U, 0036U, 0037U, 0045U, 0047U, 0048U, 0069U, 0089U, 0090U, 0091U, 0113U, 0153U, 0179U, 0211U, 0239U, 0242U, 0244U, 0245U, 0250U, 0262U, 0287U, 0288U, 0296U, 0297U, 0298U, 0299U, 0300U, 0306U, 0307U, 0313U, 0314U, 0315U, 0326U, 0329U, 0332U, 0333U, 0334U, 0339U, 0340U, 0343U, 0356U, 0362U, 0363U, 0368U, 0379U, 0388U, 0391U, 0409U, 0420U, 0421U, 0422U, 0424U, 0433U, 0444U, 0452U, 0453U, 0467U, 0478U, 0485U, 0486U, 0487U, 0496U, 0497U, 0498U, 0499U, 0501U, 0507U, 0510U, 0523U, 0530U, 0537U, 0538U, 0539U, 0549U, 0562U, 0565U, 0566U, 0569U, 0571U, 0572U, 0578U, 0585U, 0586U, 0592U, 0597U, 0611U, 0612U, 0613U, 81445, 81449, 81455, 81456, 81457, 81458, 81459, 81462, 81463, 81464, 81479, 81504, 81518, 81519, 81520, 81521, 81522, 81523, 81524, 81525, 81529, 81540, 81541, 81542, 81546, 81551, 81552, 81599, G0327.",
Motorized Spinal Traction (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 09.01.2025-03.31.2026 – This policy addresses motorized spinal traction devices. Applicable Procedure Code: S9090.

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Negative Pressure Wound Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 08.01.2025-03.31.2026 – This policy addresses negative pressure wound therapy. Applicable Procedure Codes: 97605, 97606, 97607, 97608, A6550, A9272, E2402.

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Nerve Graft to Restore Erectile Function During Radical Prostatectomy (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses autologous (sural) and allogenic nerve grafts to restore erectile function during or after radical prostatectomy. Applicable Procedure Codes: 55899, 64999.

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Neurophysiologic Testing and Monitoring (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses nerve conduction studies and other neurophysiological testing. Applicable Procedure Codes: 0106T, 0107T, 0108T, 0109T, 0110T, 0464T, 0778T, 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95873, 95874, 95885, 95886, 95887, 95905, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95937, 95999, 96002, 96004, A9279, A9280, G0255, S3900.

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Noncontact Warming Therapy, Ultrasound Therapy, and Fluorescence Imaging for Wounds (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses warming therapy, noncontact normothermic wound therapy, and low frequency ultrasound for treating wounds. Applicable Procedure Codes: 0598T, 0599T, 97610, A6000, E0231, E0232.

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Obstructive and Central Sleep Apnea Treatment (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 12.01.2025-03.31.2026 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 21142, 21199, 21206, 21685, 33276, 33277, 33278, 33279, 33280, 33281, 33287, 33288, 41512, 41530, 41599, 42140, 42145, 42299, 64570, 64582, 64583, 64584, 93150, 93151, 93152, 93153, A7049, E0485, E0486, E0492, E0493, E0530, E1399, K1027, L8679, L8680, L8686, S2080, S2900.

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Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 11.01.2025-03.31.2026 – This policy addresses occipital neuralgia and headache treatments, including occipital nerve blocks and occipital nerve ablation. Applicable Procedure Codes: 63185, 63190, 64405, 64553, 64555, 64568, 64570, 64575, 64590, 64596, 64597, 64598, 64633, 64634, 64722, 64744, 64771, 64999, A4540, L8679, L8680, L8685.

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Ocular Photoscreening (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 08.01.2025-03.31.2026 – This policy addresses instrument-based ocular photoscreening and retinal birefringence scanning/retinal polarization scanning. Applicable Procedure Codes: 0469T, 99174, 99177.

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Off-Label/Unproven Specialty Drug Treatment (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 08.01.2025-03.31.2026 – This policy addresses off-label and unproven indications of FDA-approved injectable specialty drugs.

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Omnibus Codes (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses multiple services/procedures.

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Oncology Medication Clinical Coverage (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses parameters for coverage of injectable oncology medications. Applicable Procedure Codes: A9513, A9590, A9606, A9607, A9699, J0640, J0641, J0642, J1323, J3263, J9022, J9024, J9035, J9041, J9049, J9051, J9054, J9071, J9072, J9073, J9074, J9075, J9076, J9119, J9171, J9172, J9205, J9206, J9228, J9271, J9289, J9292, J9294, J9296, J9297, J9299, J9304, J9305, J9310, J9311, J9312, J9314, J9324, J9329, J9355, J9356, J9380, Q5107, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119, Q5123, Q5126, Q5129, Q5146.

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Ophthalmologic Complement Inhibitors (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 12.01.2025-03.31.2026 – This policy addresses the use of Izervay™ (avacincaptad pegol) and Syfovre™ (pegcetacoplan injection) for the treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD). Applicable Procedure Codes: J2781, J2782.

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Orthognathic (Jaw) Surgery (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses orthognathic (jaw) surgery.

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Panniculectomy Surgery (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 12.01.2025-03.31.2026 – This policy addresses panniculectomy surgery. Applicable Procedure Codes: 15830, 15847, 15877, 15878, 15879.

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Parsabiv® (Etelcalcetide) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 05.01.2025-03.31.2026 – This policy addresses the use of Parsabiv® (etelcalcetide) for the treatment of secondary hyperparathyroidism with chronic kidney disease. Applicable Procedure Code: J0606.

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Pediatric Day Health Care (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 09.01.2025-03.31.2026 – This policy addresses pediatric day health care (PDHC) services. Applicable Procedure Codes: T1025, T1026, T2002.

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Pediatric Gait Trainers and Standing Systems (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 07.01.2025-03.31.2026 – This policy addresses pediatric gait trainers and standing systems. Applicable Procedure Codes: E0637, E0638, E0641, E0642, E8000, E8001, E8002.

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Percutaneous Patent Foramen Ovale (PFO) Closure (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses percutaneous patent foramen ovale closure for the prevention of recurrent ischemic stroke. Applicable Procedure Code: 93580.

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Percutaneous Vertebroplasty and Kyphoplasty (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 05.01.2025-03.31.2026 – This policy addresses percutaneous vertebroplasty and kyphoplasty for treating spinal pain. Applicable Procedure Codes: 22510, 22511, 22512, 22513, 22514, 22515.

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Pharmacogenetic Panel Testing (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses pharmacogenetic multi-gene panel testing. Applicable Procedure Codes: 0029U, 0173U, 0175U, 0345U, 0347U, 0348U, 0349U, 0350U, 0392U, 0411U, 0419U, 0423U, 0434U, 0438U, 0460U, 0461U, 0476U, 0477U, 0516U, 0533U, 81418, 81479.

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Plagiocephaly and Craniosynostosis Treatment (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses the use of cranial orthotic devices for treating infants following craniosynostosis surgery or for nonsynostotic (nonfusion) deformational or positional plagiocephaly. Applicable Procedure Codes: D5924, L0112, L0113, S1040.

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Pneumatic Compression Devices (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 11.01.2025-03.31.2026 – This policy addresses pneumatic compression devices. Applicable Procedure Codes: A4600, E0650, E0651, E0652, E0655, E0658, E0659, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.

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Private Duty Nursing (PDN) and Extended Home Health (EHH) Services (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2025-03.31.2026 – This policy addresses private duty nursing (PDN) and extended home health (EHH) services. Applicable Procedure Codes: S9123, S9124, T1000, T1001.

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Prolotherapy and Platelet Rich Plasma Therapies (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses prolotherapy and platelet rich plasma. Applicable Procedure Codes: 0232T, G0460, G0465, M0076, P9020.

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Prostate Surgeries and Interventions (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 08.01.2025-03.31.2026 – This policy addresses prostate surgeries and interventions, including transurethral ablation, cryoablation, surgical prostatectomy, prostatic urethral lift (PUL), high-energy water vapor thermotherapy, and transperineal placement of biodegradable material. Applicable Procedure Codes: 0421T, 0582T, 0619T, 0655T, 0714T, 0738T, 0739T, 0867T, 37243, 51721, 52441, 52442, 53850, 53852, 53854, 53855, 53865, 53866, 55873, 55881, 55882.

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Proton Beam Radiation Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 09.01.2025-03.31.2026 – This policy addresses proton beam radiation therapy. Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6001, G6002, G6015, G6016, G6017.

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Provider Administered Drugs – Site of Care (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses outpatient hospital facility-based intravenous medication infusion. Applicable Procedure Codes: 90283, 90284, J0129, J1426, J1427, J1428, J1429, J1459, J1551, J1552, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1576, J1599, J1602, J1628, J1745, J3245, J3247, J3262, J3380, J3590, Q5103, Q5104, Q5121, Q5133, Q5135, Q5156.

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Qalsody® (Tofersen) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 08.01.2025-03.31.2026 – This policy addresses the use of Qalsody® (tofersen) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1304.

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Radiation Therapy: Fractionation, Image-Guidance, and Special Services (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses radiation therapy fractionation, image-guided radiation therapy (IGRT), and special radiation therapy services. Applicable Procedure Codes: 77014, 77331, 77370, 77385, 77386, 77387, 77399, 77401, 77402, 77407, 77412, 77470, 77520, 77522, 77523, 77525, G6001, G6002, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, G6017.

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Reblozyl® (Luspatercept-Aamt) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 12.01.2025-03.31.2026 – This policy addresses Reblozyl® (luspatercept-aamt) for the treatment of anemia in adult patients with beta thalassemia and symptomatic anemia in patients with myelodysplastic syndromes or myelodysplastic/myeloproliferative neoplasms. Applicable Procedure Code: J0896.

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Rebyota® (Fecal Microbiota, Live-Jslm) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 12.01.2025-03.31.2026 – This policy addresses the use of Rebyota® (fecal microbiota, live-jslm) for prevention of the recurrence of clostridioides difficile infection (CDI). Applicable Procedure Code: J1440.

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Review at Launch for New to Market Medications (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 12.01.2025-03.31.2026 – This policy addresses review of certain new to market medications that are healthcare provider administered. Applicable Procedure Codes: C9399, J3490, J3590.

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Rhinoplasty and Other Nasal Procedures (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 08.01.2025-03.31.2026 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinoplasty, rhinophyma, nasal polypectomy, nasal septal swell body reduction, and nasal implants. Applicable Procedure Codes: 30117, 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468, 30469, 31237, 31242, 31243, 64999, L8699.

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Rituximab (Riabni®, Rituxan®, Ruxience®, & Truxima®) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 12.01.2025-03.31.2026 – This policy addresses the use of Riabni® (rituximab-arrx), Rituxan® (rituximab), Ruxience® (rituximab-pvvr), and Truxima® (rituximab-abbs). Applicable Procedure Codes: J3590, J9311, J9312, J9990, Q5115, Q5119, Q5123.

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RNA-Targeted Therapies (Amvuttra® and Onpattro®) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 10.01.2025-03.31.2026 – This policy addresses the use of Onpattro® (patisiran) and Amvuttra® (vutrisiran) for the treatment of polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis. Applicable Procedure Codes: J0222, J0225.

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Ryplazim® (Plasminogen, Human-Tvmh) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 03.01.2025-03.31.2026 – This policy addresses Ryplazim® (plasminogen, human-tvmh) for the treatment of plasminogen deficiency type 1 (hypoplasminogenemia). Applicable Procedure Code: J2998.

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Sacral Nerve Stimulation for Urinary and Fecal Indications (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses sacral nerve stimulation for urinary and fecal indications. Applicable Procedure Codes: 0784T, 0785T, 0786T, 0787T, 64561, 64581, 64585, 64590, 64595, L8679, L8680, L8682, L8685, L8686, L8687, L8688.

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Scenesse® (Afamelanotide) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 07.01.2025-03.31.2026 – This policy addresses Scenesse® (afamelanotide) for the treatment of erythropoietic protoporphyria (EPP). Applicable Procedure Code: J7352.

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Self-Administered Medications (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 11.01.2025-03.31.2026 – This policy addresses medications that are determined to be self-administered and excluded from medical coverage.

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Sinus Procedures (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 10.01.2025-03.31.2026 – This policy addresses sinus procedures. Applicable Procedure Codes: 31240, 31253. 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31295, 31296, 31297, 31298, 31299.

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Skin and Soft Tissue Substitutes (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses skin and soft tissue substitutes.

"A2001, A2002, A2004, A2005, A2006, A2007, A2008, A2009, A2010, A2011, A2012, A2013, A2014, A2015, A2016, A2017, A2018, A2019, A2021, A2026, A2027, A2028, A2029, A2030, A2031, A2032, A2033, A2034, A2035, A4100, Q4100, Q4110, Q4111, Q4112, Q4114, Q4115, Q4117, Q4118, Q4122, Q4123, Q4125, Q4126, Q4127, Q4130, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4138, Q4139, Q4140, Q4141, Q4142, Q4143, Q4145, Q4146, Q4147, Q4148, Q4149, Q4150, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4182, Q4183, Q4184, Q4185, Q4187, Q4188, Q4189, Q4190, Q4191, Q4192, Q4193, Q4194, Q4197, Q4198, Q4199, Q4200, Q4201, Q4202, Q4203, Q4204, Q4205, Q4206, Q4208, Q4209, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4224, Q4225, Q4226, Q4227, Q4229, Q4230, Q4232, Q4233, Q4234, Q4235, Q4236, Q4237, Q4238, Q4239, Q4240, Q4241, Q4242, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4251, Q4252, Q4253, Q4254, Q4255, Q4256, Q4257, Q4258, Q4259, Q4260, Q4261, Q4262, Q4263, Q4264, Q4265, Q4266, Q4267, Q4268, Q4269, Q4270, Q4271, Q4272, Q4273, Q4274, Q4275, Q4276, Q4278, Q4279, Q4280, Q4281, Q4282, Q4283, Q4284, Q4287, Q4288, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, Q4304, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310, Q4311, Q4312, Q4313, Q4314, Q4315, Q4316, Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4323, Q4324, Q4325, Q4326, Q4327, Q4328, Q4329, Q4330, Q4331, Q4332, Q4333, Q4334, Q4335, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4343, Q4344, Q4345, Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4360, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367, Q4121, Q4160, Q4186, Q4195, Q4196",
Skin Substitutes for Chronic Diabetic Lower Extremity Ulcers (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses skin and soft tissue substitutes for the treatment of partial- and full-thickness diabetic lower extremity ulcers. Applicable Procedure Codes: Q4101, Q4121, Q4154, Q4160, Q4186, Q4195, Q4196.

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Sodium Hyaluronate (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 07.01.2025-03.31.2026 – This policy addresses intra-articular injections of sodium hyaluronate. Applicable Procedure Codes: 20605, 20606, 20610, 20611, J3490, J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332.

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Somatostatin Analogs (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses the use of somatostatin analogs, including Sandostatin® (octreotide acetate), Sandostatin® LAR (octreotide acetate LAR), Signifor® (pasireotide diaspartate), Signifor® LAR (pasireotide), and Somatuline® Depot (lanreotide). Applicable Procedure Codes: J1930, J1932, J2353, J2354, J2502.

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Spinal Fusion and Bone Healing Enhancement Products (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses spinal fusion enhancement products. Applicable Procedure Codes: 0814T, 20930, 20931, 20939, 22899.

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Spinal Fusion and Decompression (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 05.01.2025-03.31.2026 – This policy addresses spinal fusion and decompression procedures, laminectomy, isolated facet fusion, dynamic stabilization systems, and total facet joint arthroplasty.

"0202T, 0219T, 0220T, 0221T, 0222T, 0719T, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 22859, 22899, 62380, 63001, 63003, 63005, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63270, 63271, 63272, 63275, 63277, 63280, 63282, 63285, 63286, 63287, 63290, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308.",
Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses stereotactic radiation therapy, including stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). Applicable Procedure Codes: 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77301, 77371, 77372, 77373, 77432, 77435, G0339, G0340, G0563.

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Subcutaneous Implantable Naltrexone Pellets (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses the use of compounded implantable drug pellets. Applicable Procedure Codes: 11981, 11982, 11983, J3490, J7999.

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Surgery for the Prevention and Treatment of Lymphedema (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses surgical procedures for the treatment or prevention of lymphedema. Applicable Procedure Codes: 1019T, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879, 38999, 49906.

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Surgery of the Elbow (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 05.01.2025-03.31.2026 – This policy addresses surgery of the elbow. Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 29830, 29834, 29835, 29836, 29837, 29838.

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Surgery of the Hip (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses surgery of the hip and femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27299, 29860, 29861, 29862, 29863, 29914, 29915, 29916, 29999, S2118.

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Surgery of the Knee (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses surgery of the knee. Applicable Procedure Codes: 0737T, 27412, 27415, 27416, 27418, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27658, 27659, 27664, 27665, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, G0428, J7330, S2112.

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Surgery of the Shoulder (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 12.01.2025-03.31.2026 – This policy addresses surgery of the shoulder. Applicable Procedure Codes: 23470, 23472, 23473, 23474, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29999.

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Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 09.01.2025-03.31.2026 – This policy addresses varicose vein ablative and stripping procedures and ligation procedures. Applicable Procedure Codes: 0744T, 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37765, 37766, 37780, 37785.

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Tepezza® (Teprotumumab-Trbw) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses the use of Tepezza® (teprotumumab-trbw) for the treatment of thyroid eye disease. Applicable Procedure Code: J3241.

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Testosterone Replacement or Supplementation Therapy (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses the use of injectable testosterone and testosterone pellets for replacement therapy in conditions associated with a deficiency or absence of endogenous testosterone. Applicable Procedure Codes: 11980, J1071, J1072, J1073, J3121, J3145.

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Total Artificial Disc Replacement for the Spine (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0098T, 0165T, 22856, 22857, 22858, 22860, 22861, 22862, 22899.

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Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses transarterial radioembolization (TARE)/selective internal radiation therapy (SIRT) using yttrium-90 microspheres for the treatment of malignant cancers of the liver. Applicable Procedure Codes: 37243, 75984, 79445, S2095.

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Transcatheter Procedures for Heart Valve Conditions (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses transcatheter heart valve (aortic, pulmonary, mitral) procedures. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0543T, 0544T, 0545T, 0569T, 0570T, 0646T, 0805T, 0806T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33370, 33418, 33419, 33477, 93799.

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Transcranial Magnetic Stimulation (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 07.01.2025-03.31.2026 – This policy addresses transcranial magnetic stimulation and navigated transcranial magnetic stimulation (nTMS). Applicable Procedure Codes: 0858T, 0889T, 0890T, 0891T, 0892T, 90867, 90868, 90869.

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Treatment of Temporomandibular Joint Disorders (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses treatment of temporomandibular joint (TMJ) disorders. Applicable Procedure Codes: 20552, 20553, 20605, 20606, 21010, 21050, 21060, 21070, 21085, 21089, 21110, 21240, 21242, 21243, 21247, 21299, 21499, 29800, 29804, 90901, 97039, 97139, E0746, E1399, E1700, E1701, E1702.

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Upper Extremity Prosthetic Devices (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 11.01.2025-03.31.2026 – This policy addresses upper extremity prosthetic devices. Applicable Procedure Codes: L6026, L6028, L6034, L6035, L6036, L6038, L6611, L6621, L6629, L6632, L6677, L6680, L6682, L6686, L6687, L6688, L6694, L6695, L6696, L6697, L6698, L6715, L6880, L6881, L6882, L6883, L6884, L6890, L6925, L6935, L6945, L6955, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191, L7259, L7360, L7364, L7366, L7367, L7368, L7400, L7401, L7403, L7404, L7406, L8465.

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Vagus and External Trigeminal Nerve Stimulation (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 03.01.2026-03.31.2026 – This policy addresses implantable vagus nerve stimulators and transcutaneous (non-implantable) vagus and trigeminal nerve stimulators. Applicable Procedure Codes: 61885, 61886, 64553, 64568, 64570, A4541, E0733, E0735, E0770, E1399, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688.

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Veopoz® (Pozelimab-Bbfg) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 08.01.2025-03.31.2026 – This policy addresses the use of Veopoz® (pozelimab-bbfg) for the treatment of CD55-deficient protein-losing enteropathy (PLE) (i.e., CHAPLE disease). Applicable Procedure Code: J9376.

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Vertebral Body Tethering for Scoliosis (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 06.01.2025-03.31.2026 – This policy addresses vertebral body tethering for the treatment of scoliosis. Applicable Procedure Codes: 0656T, 0657T, 0790T, 22836, 22837, 22838, 22899.

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Virtual Upper Gastrointestinal Endoscopy (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses virtual upper gastrointestinal endoscopy. Applicable Procedure Codes: 76497, 76498.

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Visual Information Processing Evaluation and Orthoptic and Vision Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 05.01.2025-03.31.2026 – This policy addresses occlusion therapy, pharmacologic penalization therapy, orthoptic or vision therapy, prism adaptation therapy, visual perception therapy, vision restoration therapy, and the use of visual information processing evaluations to diagnose reading or learning disabilities. Applicable Procedure Codes: 0687T, 0688T, 0704T, 0705T, 0706T, 92065, 92066, 92499.

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Walkers and Walker Accessories (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 07.01.2025-03.31.2026 – This policy addresses the use of walkers. Applicable Procedure Codes: A4636, A4637, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0152, E0154, E0155, E0156, E0157, E0158, E0159; E1399.

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Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2026

Effective Date: 02.01.2026-03.31.2026 – This policy addresses whole exome and whole genome sequencing. Applicable Procedure Codes: 0094U, 0212U, 0213U, 0214U, 0215U, 0260U, 0264U, 0265U, 0266U, 0267U, 0335U, 0336U, 0425U, 0426U, 0454U, 0469U, 0532U, 0567U, 81354, 81415, 81416, 81417, 81425, 81426, 81427.

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Xiaflex® (Collagenase Clostridium Histolyticum) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2026

Effective Date: 01.01.2026-03.31.2026 – This policy addresses the use of Xiaflex® (collagenase clostridium histolyticum) for the treatment of Dupuytren’s contracture and Peyronie’s disease. Applicable Procedure Codes: 20527, 26341, J0775.

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✕

Community Plan of Louisiana Medical & Drug Policies Terms and Conditions

The UnitedHealthcare Community Plan for Louisiana is no longer active as of Apr. 1, 2026.

Please read the terms and conditions below carefully.

UnitedHealthcare has developed Medical Policies and Medical Benefit Drug Policies to assist us in administering health benefits. These policies are provided for informational purposes and do not constitute medical advice. Treating physicians and health care providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.

Our Medical Policies and Medical Benefit Drug Policies express our determination of whether a health service (e.g., test, device, or procedure) is proven to be effective based on the published clinical evidence. They are also used to decide whether a given health service is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered.

Benefit coverage for health services is determined by the member specific benefit plan document, such as a Certificate of Coverage, Schedule of Benefits, or Summary Plan Description, and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes these policies.

Medical Policies and Medical Benefit Drug Policies represent a portion of the resources used to support UnitedHealthcare coverage decision making. The information presented in these policies is believed to be accurate and current as of the date of publication and is provided on an "AS IS" basis. Additionally, UnitedHealthcare may use tools developed by third parties, such as the InterQual® criteria, to assist us in administering health benefits. The InterQual® criteria are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.

Medical Policies and Medical Benefit Drug Policies are the property of UnitedHealthcare. Unauthorized copying, use, and distribution of this information are strictly prohibited. The InterQual® criteria are proprietary to Optum and are not published on this website.

When these policies are used to determine medical necessity, clinical guidelines will be applied in the following order:

  1. State/Federal Guidelines and Contract Requirements
  2. UnitedHealthcare Community Plan of Louisiana Medical & Drug Policies
  3. InterQual® criteria

By clicking "I Agree," you agree to the terms and conditions expressed herein, in addition to our Site Use Agreement.