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Notification of Medicare Medical Coverage Policies Revisions October 2025
Medical Policy NameSummary of Changes
Medicare Part C Medicare Coverage Policy Temporomandibular Joint Dysfunction Surgery 

Annual Review. 

Updated language to align with Corporate Policy.

Added references to include Medicare Benefit Policy and MCG guidelines.

No change to policy intent

Medicare Part C Medicare Coverage Policy Forsee AMD Home Monitoring 

Annual Review.

Added references

Added indication for non-coverage per external physician review

No change to policy intent. 

Medicare Part C Medicare Coverage Policy Upper Limb Prosthetics

Annual Review.

This policy was updated as the codes on this policy are billed under prosthetic benefit and therefore require prior approval from the Plan. No CMS guidance to update. Myoelectric codes removed as they are now billed under DME benefit.

Added references

No change to policy intent. 

Medicare Part C Medicare Coverage Policy Ambulance and Medical Transport Services

Converted to a Policy in the absence of an NCD or LCD. No CMS Guidance updates. Added additional language regarding the criteria for a fixed or rotary winged ambulance.

Added references 

No change to policy intent.

Medicare Part C Medical Coverage Policy Intensive Outpatient Program (IOP) Behavioral Health 

Newly created policy for MA Behavioral Health in absence of an NCD or LCD

accessed on 08/18/2025

Medicare Part C Medical Coverage Policy Pneumatic Compression Device for Chest, Trunk, Abdomen, Head and Neck 

Newly created policy in the absence of CMS guidance on the use of a PCD for chest, trunk or abdomen as standalone treatment.

Medicare Part C Medical Coverage Policy Bioengineered Skin and Soft Tissue Substitute for Breast Reconstruction, Epidermolysis Bullosa Dystrophica (EBD), and Severe Burns

Newly created policy in absence of current NCDLCD and LCA.

Blue Cross and Blue Sheild NC Corporate Policy Skin and Soft Tissue Substitutes; Originated January 1994 via Skin and Soft Tissue Substitutes | Providers | Blue Cross NC accessed on 08/11/2025 

Proposed LCD-Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers (DL39806) accessed on 8/11/2025 

Proposed Local Coverage Article (LCA) Billing and Coding: Skin Substitutes Grafts/Cellular Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers Draft Article - Billing and Coding: Skin Substitutes Grafts/Cellular Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers (DA59740) accessed on 8/11/2025 

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