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Johns Hopkins Health Plans

Medical Policies Update Provider Notification

The below listed medical policies have been approved by the Johns Hopkins Health Plans Medical Policy Advisory Committee (MPAC). Changes and additions are effective Oct. 1, 2026. Full text copies of these policies are available upon request by contacting Provider Relations. The policies will be posted in the Johns Hopkins Health Plans Medical Policy Manual on the effective date: Oct. 1, 2026. 

Revised Medical Policies, Retired Policies and Focused Updates

Revised Policies Effective Oct. 1, 2026

  • CMS21.01 - Neuromodulation for Bladder and Bowel Dysfunction (Formerly: “Neuromodulation for Overactive Bladder, Urinary Retention and Fecal Incontinence)
    • Health Plans: Advantage MD, Employer Health Programs, Johns Hopkins Health Plans of Virginia, US Family Health Plan, Priority Partners
    • The policy title was changed to Neuromodulation for Bladder and Bowel Dysfunction to better reflect the full scope of conditions addressed.
    • Clinical criteria remain unchanged. 
    • Revision focused on removing redundancies and improving structural clarity to streamline the policy and make navigation easier for reviewers. 
    • Our review of regulatory guidance, evidence-based literature and industry standards found no new clinical or regulatory developments that would require changes to the coverage criteria.
  • CMS11.02 - Preventive Health Guidelines
    • Health Plans: Advantage MD, Employer Health Programs, Johns Hopkins Health Plans of Virginia, US Family Health Plan, Priority Partners
    • This policy is informational only and is not used in Utilization Management decision making. It is required for regulatory compliance.
    • The policy serves as a resource to help providers screen for chronic disease and deliver preventive care. Johns Hopkins Health Plans Care Management also uses it when developing health education materials for plan members.
    • No changes were made to the existing policy content.
    • Updated links were added for the following Preventive Health Guidelines:
      • Centers for Disease Control and Prevention (CDC). Infection Control Guidance - Respiratory Viruses.
      • Department of Agriculture (USDA)/ Department of Health and Human Services (HHS): 2025-2030 Dietary Guidelines for Americans
  • CMS 16.02 - Treatment for Skin Conditions
    • Health Plans: Advantage MD, Employer Health Programs, Johns Hopkins Health Plans of Virginia, US Family Health Plan, Priority Partners
    • A comprehensive review of regulatory guidance, evidence-based literature and current industry standards for the treatment of skin conditions was completed. 
    • The evidence review showed that PUVA (Psoralen medication plus Ultraviolet A light) therapy is no longer supported as an effective or standard of care treatment for alopecia areata. 
    • Accordingly, PUVA modality has been reclassified within the policy as investigational and experimental for this indication.
    • Utilization review data demonstrated no prior authorization requests and no claims for PUVA treatment for alopecia areata within the past 24 months, further supporting the policyrevision.
    • Administrative updates were also made to remove references to services that no longer require medical necessity review or in scope with the policy.
  • CMS19.07 - Stretching Devices for the Treatment of Joint Stiffness & Contracture
    • Health Plans: Advantage MD, Employer Health Programs, Johns Hopkins Health Plans of Virginia, US Family Health Plan, Priority Partners
    • The policy was updated to expand coverage of stretching devices used in the treatment of joint stiffness and contracture. 
    • Key changes include: 
      • Stretching devices for the shoulder joint are no longer considered investigational and have been added to InterQual® clinical criteria. The corresponding section of the policy was updated accordingly.
      • InterQual does not address lower extremity joints. The current policy included criteria only for the knee, not addressing other joints specifically.  
      • Codes for ankle and toe stretching devices are now covered by Maryland Medicaid and Medicare.
      • New medical necessity criteria were developed for these lower-extremity joints, aligned with the formatting of InterQual’s upper extremity criteria for consistency.
      • The revised policy was reviewed by the subject matter expert, and their recommendations alone with the supporting references were incorporated.
      • Additional updates include formatting improvements, streamlining content, and removing information that is not essential to coverage decision-making.
  • CMS23.07 - Infertility Treatment & Fertility Preservation
    • Health Plans: Advantage MD, Employer Health Programs, Johns Hopkins Health Plans of Virginia, US Family Health Plan, Priority Partners
    • The policy was revised to clarify infertility evaluation and treatment benefits, assistive reproductive technology and fertility preservation benefits for each line of business, as coverage varies significantly across plans.
    • A new Plan-Specific Benefits Overview section was added to provide a concise summary of covered benefits by health plan, improving usability for Utilization Management (UM).
    • Clinical criteria related to infertility diagnosis and treatment were removed because they are not used for UM determinations. The Summary Plan Description provides criteria for EHP infertility treatment. 
    • Additional revisions were made throughout the policy to improve organization and readability.

Retired Policies Effective Oct. 1, 2026

  • CMS03.08 - Panniculectomy
    • Health Plans: Advantage MD, Employer Health Programs, Johns Hopkins Health Plans of Virginia, US Family Health Plan, Priority Partners
    • The policy will be retired, and InterQual® criteria will be used for medical necessity review.
    • A crosswalk comparing the Johns Hopkins Health Plans Medical Policy and InterQual® Criteria was completed.
      • InterQual Procedures criteria are based on a systematic, ongoing review and critical appraisal of current evidence-based literature, supplemented by input from an independent panel of clinical experts.
    • For CMS03.08 Panniculectomy, InterQual criteria closely align with the Johns Hopkins Health Plans Medical Policy:
      • The key difference is that InterQual does not require documentation of smoking status. 
      • Johns Hopkins Health Plans Medical Policy includes “Member is not an active smoker” as part of the required clinical documentation. 
      • InterQual does not reference smoking status in its Panniculectomy Criteria and does not list active smoking as a contraindication for the procedure. 
    • Regulatory sources such as Medicare, TRICARE®, and COMAR, do not include requirements related to smoking status, and major industry policies likewise do not specify smoking or non-smoking criteria for panniculectomy.

Focused Updates Effective Oct. 1, 2026

  • CMS24.26 - Cell and Gene Therapy Access Model - PPMCO
    • Health Plans: Priority Partners
    • An administrative update was made to incorporate the new Maryland Department of Health (MDH) provider transmittal PT 83 26, effective May 12, 2026:
      • The University of Maryland Medical Center (UMMC) is now approved as a treatment center for CASGEVY. 
      • The previous policy listed UMMC as a treatment center for LYFGENIA only, based on earlier MDH communication.
  • CMS23.05 - Site of Service- Outpatient Surgical Procedures
    • Health Plans: Advantage MD, US Family Health Plan, Priority Partners
    • This focused update includes administrative revisions. No changes to policy clinical content. 
    • Per Cost of Care Committee recommendations, the following CPT codes were added to policy for the site of service redirection to Ambulatory Surgical Centers: 
      • 37242 & 37243 - Vascular embolization or occlusion procedures performed on blood vessels
      • 23472 – Total shoulder replacement

Policies with No Changes in Criteria

An evaluation of regulatory policies, evidence-based literature research, and industry standards was conducted. Each section links and references were reviewed and updated.

  • CMS11.01 - Clinical Practice Guidelines
    • Health Plans: Advantage MD, Employer Health Programs, Johns Hopkins Health Plans of Virginia, US Family Health Plan, Priority Partners
    • No changes made to policy criteria
  • CMS04.03 - Pharmacogenomics
    • Health Plans: Employer Health Programs, US Family Health Plan
    • No changes made to policy criteria
  • CMS23.08 - Site of Service - Sleep Studies
    • Health Plans: Advantage MD, Employer Health Programs, Johns Hopkins Health Plans of Virginia, US Family Health Plan, Priority Partners
    • No changes made to policy criteria
  • CMS24.16 - Genicular Nerve Treatments for Chronic Knee Pain
    • Health Plans: Advantage MD, Johns Hopkins Health Plans of Virginia, Priority Partners
    • No changes made to policy criteria