February 5, 2026
The following policies received their annual review with changes noted below:
Hospital or Hospital System Readmissions
- In the definitions section, added a new definition for “clinically related.”
- In the policy section, added "Effective with claim dates of service on and after May 8, 2026, the plan may deny reimbursement of unplanned inpatient readmission claims for clinically related conditions within 30 calendar days of discharge from the same hospital or hospital system.
Some examples of clinically related conditions include the following:
- Surgical complications
- Follow-up care after prior admission
- Surgical site infections
- Pneumonia associated with ventilator services
- Catheter associated urinary tract infections
- Catheter associated blood stream infections
- Venous thromboembolism after missed opportunity for prophylaxis
- Additional hospitalization readmission due to lack of available services and supplies during the first hospital inpatient admission
Intensity Modulated Radiation Therapy (IMRT)/Proton Beam Therapy Planning and Treatment Coding – Outpatient Facility claims
- Updated code 77014 with code termination date of January 1, 2026.