Provider Connection
Medical Policy Updates – November Newsletter 2025
Provider Connection
Medical Policy Updates – November Newsletter 2025
University of Utah Health Plans uses medical policies as guidelines for coverage determinations in accordance with the member’s benefits. Quarterly notice of recently approved and revised medical policies is provided in Provider Connection for your convenience. The Medical Policy Updates section of this newsletter does not indicate that coverage is provided for the procedures listed.
| NEW POLICIES | |||
|---|---|---|---|
| Policy Number | Policy Name | Effective Date | Summary |
| MP-034 (New) | Single Photon Emission Computed Tomography (SPECT) (single-day, single area SPECT/CT scan) | 07/28/2025 | Commercial Plan: U of U Health Plans considers SPECT-CT fusion medically necessary for parathyroid imaging, when all other testing has been inconclusive or non-diagnostic, in persons who meet certain criteria. Please see the policy for further details. Please see the policy for further details. |
| REVISED POLICIES | |||
|---|---|---|---|
| Policy Number | Policy Name | Effective Date | Summary |
| MP-042 (Revised) | Electric Tumor Treatment Field Therapy | 05/21/2025 | Commercial Plan: U of U Health Plans added a new criterion for an FDA approved coverage of tumor treatment field therapy for the treatment of glioblastoma multiforme which is a “good performance status (KPS > 60)”. |
| MP-056 (Revised) | Vitamin D Testing | 05/21/2025 | Commercial Plan: U of U Health Plans included 2 new diagnoses to the policy for vitamin D testing. Eating disorders and osteopenia (with a high FRAX score of >3% 10-year probability of hip fracture or 20% 10-year probability of other major osteoporotic fracture; or a T score between −1.0 and −2.49). |
| MP-006 (Revised) | DNA Analysis of Stool for Colon Cancer Screening (Cologuard®) | 06/18/2025 | Commercial Plan: Updated policy to specify testing once every three years for average-risk individuals. |
| MP-052 (Revised) | Bariatric Surgery | 07/27/2025 | Commercial Plan: Updated BMI cutoffs to align with the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) and the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines. |
| MP-057 (Revised) | DecisionDx® Testing for Melanoma | 08/27/2025 | Commercial Plan: Title change from “Genetic Testing for Melanoma” to “DecisionDx® Testing for Melanoma” |
| MP-060 (Revised) | CO2 (Carbon Dioxide) Fractional Ablative Laser Treatment for Burn and Hypertrophic Scars | 08/27/2025 | Commercial Plan: The policy title now includes “hypertrophic scars” and adds coverage for fractional CO₂ laser treatment of hypertrophic burn, traumatic, and surgical scars when conventional therapies have failed. |
| MP-062 (Revised) | Fecal Microbiota Transplant | 08/27/2025 | Commercial Plan: Updated policy from at least “3” episodes of recurrent mild to moderate CDI to at least “2”. |
| ARCHIVED POLICIES | |||
|---|---|---|---|
| Policy Number | Policy Name | Effective Date | |
| ADMIN-006 (Archived) | Women's Health & Cancer Rights Act Clarification (WHCRAC) | 07/23/2025 | |
| ADMIN-017 (Archived) | Temporary COVID-19 Telemedicine Policy | 05/28/2025 | |
| MP-007 (Archived) | Ambulatory Insulin Pumps and Closed Loop Insulin Delivery System | 08/27/2025 | |
| MP-008 (Archived) | Continuous Glucose Monitor (CGM) | 08/27/2025 | |
| MP-013 (Archived) | Allergy Testing | 08/27/2025 | |
| MP-018 (Archived) | Cell-Free DNA (cfDNA) testing for Fetal Aneuploidy | 08/27/2025 | |
| MP-044 (Archived) | Flow Cytometry | 07/23/2025 | |
| MP-049 (Archived) | Sacroiliac Joint (SI) Joint Fusion | 08/27/2025 | |
| MP-055 (Archived) | Homocysteine Level Testing | 07/23/2025 | |
| MP-067 (Archived) | Speech Generating Devices | 07/23/2025 | |
| MP-079 (Archived) | Arthroereisis and Subtalar Implants | 08/27/2025 | |