Quick Overview
Policy Updates
- Scope of Practice Requirements
- Key Reminders
Policy Bulletin
July 2026 Policy Updates
New Policies
Category
Policy Title (Number)
Date
Summary of Change
Coding/Reimbursement
6/1/2026
Created and published this coding/reimbursement policy.
Revised Policies
*Changes apply ONLY to Commercial plan policy UNLESS summary text appears in bold.
Category
Policy Title (Number)
Date
Summary of Change
Ear, Nose, and Throat
5/27/2026
For Commercial Plan Policy, clarified requirements to qualify for coverage of a Baha Softband: “The use of a Baha Softband may be considered medically necessary in children 5 years of age and younger who meet criteria for bone-anchored hearing aids, but who are determined to have inadequate skeletal maturity as defined by a skull thickness of less than 3 mm."
Ear, Nose, and Throat
6/3/2026
Modified title of policy by removing the word benign (“Radiofrequency Ablation for Thyroid Nodules”), to eliminate focus only on coverage of this treatment for benign thyroid nodules and to also allow consideration of coverage for select cases of thyroid carcinoma.
For Commercial Plan Policy, added the following qualifying option to coverage criteria: “Select Health covers radiofrequency ablation for T1N0M0 differentiated thyroid carcinoma as an alternative to surgical resection.”
General Surgery
6/12/2026
For Commercial Plan Policy, added the following clarification: “Note: For Liposuction for Lymphedema, please see Select Health medical policy #688.”
General Surgery
6/18/2026
For Commercial Plan Policy, added new criteria section #D for consideration of coverage for ligation/stripping and phlebectomy procedures.
Genetic Testing
6/15/2026
For Commercial Plan Policy, clarified requirements in both the section header of criteria #3: “Select Health covers germline panel testing for breast, ovarian, prostate, and pancreatic cancer susceptibility genes …” and in criterion #3F-3: “a personal or family history of a known germline pathogenic or likely pathogenic variant in a breast, ovarian, pancreatic, and/or prostate cancer susceptibility gene …”; and added new criterion #4 regarding coverage of updated germline hereditary cancer gene panel testing.
Genetic Testing
6/15/2026
For Commercial Plan Policy, clarified requirements in header of criteria section #3: “Select Health covers multi-marker tumor panels once per specific tumor diagnosis using next-generation sequencing in the diagnosis and treatment of cancer as a method to guide the selection of therapeutic agents for malignant tumors in limited circumstances. Panels may include combined or separate DNA and RNA analysis; however, separate RNA analysis is only allowed if DNA testing has been performed previously or is being performed concurrently. …”; and added new criterion #4 regarding coverage of repeat multi-marker tumor panels using next-generation sequencing.
Genetic Testing
6/5/2026
For Commercial Plan Policy, included new section #16, which includes coverage criteria for the Decipher Prostate, Biopsy Genomic Classifier, Genomic Prostate Score Test (GPS), and Prolaris tests, and exclusion of the ArteraAI test.
Genetic Testing
6/18/2026
For Commercial Plan Policy, removed previous section #2, which included coverage criteria for the PrismRA test, and included this test as excluded from coverage in section #1.
Pediatrics
6/18/2026
For Commercial Plan Policy, updated overall coverage criteria to align with current clinical standards, and added new criteria sections #7 (Twin Anemia and Polycythemia Sequence [TAPS]), #10 (Placental Tumor), and #11 (Fetal Airway mass) for consideration of coverage for these procedures.
Pharmacology
6/5/2026
Modified title of policy, “Diagnostic Testing for Chronic Fatigue Syndrome (CFS)/Myalgic Encephalomyelitis”
For Commercial Plan Policy, added the following tests to list of denied diagnostic tests when used for CFS: “Home microbiome tests, Mitochondrial function tests, Oxidative stress panels, and Salivary cortisol test.”
Physical Medicine
5/22/2026
For Commercial Plan Policy, included coverage criteria for both Initial Admissions and Continued Stays.
Physical Medicine
6/5/2026
For Commercial Plan Policy, added the following language which clarifies requirements outlined in criteria section #I-A2: “For cervical (C1-C2), medial branch blocks should not be performed but should follow the criteria for diagnostic and therapeutic facet joint injections. This is due to the variability of medial branch intervention at this level.”
Pulmonary
5/30/2026
For Commercial Plan Policy, added clarifying footnote to criterion #III-A1: “*The American Academy of Sleep Medicine (AASM) distinguishes between the AHI and RDI based on the types of respiratory events each index includes. The AHI counts apneas and hypopneas per hour of sleep, while the RDI = (apneas + hypopneas + RERAs) × 60 / total sleep time, adding respiratory effort-related arousals (RERAs) to the calculation. Respiratory effort-related arousals (RERAs) are respiratory events during sleep characterized by ≥ 10 seconds of increasing upper airway respiratory effort that terminates in an EEG-based arousal from sleep, without meeting the criteria for an apnea or hypopnea. They represent a form of partial upper airway obstruction that causes sleep fragmentation without significant airflow reduction or oxygen desaturation.”
Women's Health
6/18/2026
For Commercial Plan Policy, modified coverage criterion #2: “Select Health covers contralateral mastectomy for symmetry purposes in individuals undergoing mastectomy for the contralateral breast for primary malignancy.”
Additional Announcements
- Effective July 1, 2026, medical policy #160 (Pectus Excavatum Surgery) will be archived and the following CPT codes will be covered without review:
- 21740
- 21742
- 21743
- Effective August 1, 2026, for the following medical policies, the additional portion in bold will be required in conjunction with the existing requirements for approval of attempts at conservative therapy.
- #622 Cervical, Lumbar, and Thoracic Spinal Fusion with or without Spinal Decompression
- #557 Radiofrequency Ablation of the Genicular Nerve
- #389 Radiofrequency Ablation (RFA) of the Sacroiliac (SI) Joint
- #648 Intracept
- #654 Peripheral Nerve Stimulation
- #609 Infusion Pumps
- #595 Sacroiliac Joint Fusions
- #626 Diagnostic and Therapeutic Interventions for Spinal Pain
"Minimum of 12 physical therapy visits or chiropractic visits treating the area that requires the intervention within a 6-month period; must have been performed within the previous year (it is recommended that at least four of these visits be performed in-person). After 6 visits, additional therapy is not required if contraindicated or not recommended by the physical or chiropractic therapist.
Documentation submitted needs to include the evaluation, treatment plan, expectations for improved outcomes, and duration of therapy to meet this requirement."
- The following genetic testing medical policies have been archived, effective June 1, 2026. Review of claims associated with these policies are now evaluated with new Select Health genetic testing medical policies which utilize Concert-adopted criteria.
- #240 Genetic Testing: Hereditary Hemorrhagic Telangiectasia (HHT)
- #289 Genetic Testing: Cystic Fibrosis (CF)
- #385 Genetic Testing: Arrythmia
- #438 Genetic Testing: PTEN Mutation Analysis
- #510 Genetic Testing and Biomarkers for Screening and Detection of Prostate Cancer
- #530 Genetic Testing: Age-Related Macular Degeneration
- #538 Gene Expression Testing for Indeterminate Thyroid Nodule Biopsy
- #544 Genetic Testing for Prostate Cancer Prognosis
- #586 Genetic Testing: Rett Syndrome
- #594 Genetic Testing: Use of 5-Flourouracil in Cancer Patients
- #600 Genetic Testing: Spinal Muscular Atrophy
- #666 Genetic Testing: Hearing Loss
- #678 Genetic Testing: Barrett's Esophagus
- #680 Gene Expression Profiling: Uveal Melanomas
Coding Updates
Scope of Practice Requirements
Providers are responsible for billing only those services that fall within the scope of their licensure and professional practice. Benefit coverage does not override scope-of-practice requirements.
Services performed or billed outside a provider’s scope of practice may be denied as not covered for that provider type, even if the service is otherwise eligible for coverage under the member’s benefits.
For example, trigger point injections are not covered when billed by chiropractors because they fall outside the scope of chiropractic practice in all states where Select Health has coverage.
Key Reminder
- Verify that all billed services are within your licensed scope of practice.
- Do not rely on member benefit coverage alone when determining whether a service is appropriate to bill.
- Claims submitted for services outside your scope may be denied, even if the service itself is a covered benefit.