Medical Policy and Coding Updates

Effective July 2, 2026

Drugs for Rare Diseases, 5.01.576  PBC | Premera HMO
Medical necessity criteria added

• Givlaari (givosiran) is subject to review for site of service administration.

Immune Checkpoint Inhibitors, 5.01.591  PBC | Premera HMO
Medical necessity criteria updated

• Keytruda Qlex (pembrolizumab and berahyaluronidase alfa-pmph) SC is subject to review for site of service administration.

Immune Globulin Therapy, 8.01.503  PBC | Premera HMO
Medical necessity criteria added

• Yimmugo (immune globulin intravenous, human-dira) is subject to review for site of service administration.

Medical necessity criteria updated

• Guillain-Barre syndrome treatment criteria now requires severe disease with significant weakness and initiation of treatment within 4 weeks of symptom onset.
• Multifocal motor neuropathy criteria now requires stepwise or slowly progressive asymmetric limb weakness for at least 1 month, motor involvement of at least 2 nerves on nerve conduction studies, and normal sensory nerve conduction studies except for minor vibration loss in the lower limbs.
• Neuromyelitis optica spectrum disorder criteria now allows diagnosis confirmation based on a single clinical characteristic.
• Antiphospholipid syndrome criteria now allows catastrophic antiphospholipid syndrome when plasma exchange is not an option and intravenous immunoglobulin is not used as chronic or prophylactic therapy.

Pharmacologic Treatment of High Cholesterol, 5.01.558  PBC | Premera HMO
Medical necessity criteria added

• Leqvio (inclisiran) is subject to review for site of service administration.

Pharmacologic Treatment of Transthyretin-Mediated Amyloidosis, 5.01.593  PBC | Premera HMO
Medical necessity criteria added

• Amvuttra (vutrisiran) and Onpattro (patisiran) are subject to review for site of service administration.

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  PBC | Premera HMO
Medical necessity criteria added

• Rystiggo (rozanolixizumab-noli) is subject to review for site of service administration.

Medical necessity criteria updated

• Voyxact criteria revised to lower urine protein-to-creatinine ratio (UPCR) thresholds, add an estimated Glomerular Filtration Rate greater than or equal to 30 mL/min/1.73 m² requirement, exclude individuals on dialysis or post‑transplant, and require prior inadequate response or intolerance to Filspari or Tarpeyo.

Prostate Artery Embolization, 7.01.55  PBC | Premera HMO
New policy

• Prostate artery embolization is considered investigational as a treatment for benign prostatic hyperplasia.

Reconstructive Breast Surgery/Management of Breast Implants, 7.01.533  PBC | Premera HMO
Medical necessity criteria updated

• Poland syndrome added to the list of breast conditions for which reconstructive breast surgery may be considered medically necessary when criteria are met.

Site of Service: Infusion Drugs and Biologic Agents, 11.01.523  PBC | Premera HMO
New policy

• Amvuttra (vutrisiran), Onpattro (patisiran), Yimmugo (immune globulin), Givlaari (givosiran), Keytruda Qlex (pembrolizumab and berahyaluronidase alfa‑pmph), Leqvio (inclisiran), and Rystiggo (rozanolixizumab‑noli) are subject to review for site of service administration.

Effective July 1, 2026

Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525  PBC | Premera HMO
Title change

• Updated from Site of Service Ambulatory Service Center Select Surgical Procedures to Site of Service Ambulatory Service Center Select Surgical or Diagnostic Procedures in Adults.

Medical necessity criteria added

• Upper Gastrointestinal Endoscopy is subject to review for site of service.

Upper Gastrointestinal (UGI) Endoscopy in Adults, 2.01.533  PBC | Premera HMO
Title change

• Updated from Upper Gastrointestinal (UGI) Endoscopy for Adults to Upper Gastrointestinal (UGI) Endoscopy in Adults.

Medical necessity criteria added

• Upper Gastrointestinal Endoscopy is subject to review for site of service.

Effective June 5, 2026

Carpal Tunnel Release Surgical Treatments, 7.01.595  PBC | Premera HMO
Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525  PBC | Premera HMO
Medical necessity criteria updated

• Carpal Tunnel Release Surgical Treatments are subject to review for site of service.

Intracoronary Drug Delivery Balloon Procedures, 7.01.97  PBC | Premera HMO
New policy

• The use of percutaneous coronary intervention with a drug-coated balloon for the treatment of intracoronary in-stent restenosis is considered investigational.

Effective for dates of service on and after June 5, 2026, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Radiation Therapy. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

Radiation Therapy Program Expansion

Addition of Electronic Brachytherapy – Skin and Orthovoltage

• Clinical indications:
  • Treatment of non‑melanoma skin cancers, including basal cell carcinoma and squamous cell carcinoma.
  • Use in select non‑malignant conditions.

Non-malignant disease review

• Carelon will implement specific appropriate use criteria for radiation therapy in non‑malignant diseases including:
  • Keloid prevention
  • Dupuytren’s contracture
  • Ledderhose contracture
  • Peyronie’s disease
  • Plantar fasciitis
• Radiation therapy recognized as a low‑dose treatment option for certain benign proliferative and inflammatory conditions.
• Non‑malignant indications reviewed under Carelon’s non‑malignant disease clinical guidelines.

For questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines.

Effective April 8, 2026

Mobile Cardiac Telemetry and Implantable Loop Recorders, 2.02.510  PBC | Premera HMO
Title changed

• Updated from Mobile Cardiac Outpatient Telemetry to Mobile Cardiac Telemetry and Implantable Loop Recorders

Medical necessity criteria added

• Implantable loop recorders may be considered medically necessary when criteria are met.
• Mobile cardiac telemetry and implantable loop recorders are subject to review for site of service.

Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525  PBC | Premera HMO
Medical necessity criteria added

• Mobile cardiac telemetry and implantable loop recorders are subject to review for site of service.

Revised medical policies
Effective April 1, 2026

Abdominal Wall Hernias in Adults, 7.01.600  PBC | Premera HMO
Medical necessity criteria updated

• Initial hernia repair no longer requires prior conservative management.

Bariatric Surgery, 7.01.516  PBC | Premera HMO
Medical necessity criteria updated

• Single anastomosis duodeno‑ileal bypass with sleeve gastrectomy was moved from the investigational category to the list of bariatric procedures considered medically necessary when criteria are met.

Blepharoplasty, Blepharoptosis and Brow Ptosis Surgery, 7.01.508  PBC | Premera HMO
Cosmetic and Reconstructive Services, 10.01.514  PBC | Premera HMO
Medical necessity criteria added

• Canthoplasty/canthopexy may be considered medically necessary when performed to address functional eye conditions such as excessive tearing, severe corneal dryness, or corneal ulceration.

Prescription Digital Therapeutics, 13.01.500  PBC | Premera HMO
Investigational criteria updated

• SleepioRX now included in the list of digital therapeutic devices considered investigational.
• Mahana for IBS [irritable bowel syndrome], d‑Nav Insulin Management, and Regulora for IBS, removed from the list of digital therapeutic devices as these products are no longer marketed in the United States.

Pulsed Radiofrequency for the Treatment of Chronic Pain, 7.01.564  PBC | Premera HMO
Investigational criteria updated

• The following conditions were added to the list of chronic pain syndromes for which pulsed radiofrequency is considered investigational:
  • Calcaneal (heel) spur
  • Cervical, thoracic, and lumbosacral radicular pain (such as dorsal root ganglion)
  • Glossopharyngeal neuralgia
  • Idiopathic axonal polyneuropathy
  • Idiopathic supraorbital neuralgia
  • Infraorbital neuralgia
  • Intercostobrachial neuralgia associated with post-mastectomy pain syndrome
  • Interstitial cystitis
  • Lumbar herniated nucleus pulposus
  • Myofascial or neuromatous pain
  • Peripheral nerve involvement due to tumors
  • Peripheral post-traumatic neuropathic pain
  • Periscapular pain
  • Stump pain
  • Thoracic pain
  • Zygapophyseal joint pain

Shoulder Arthroscopy in Adults, 7.01.602  PBC | Premera HMO
Medical necessity criteria updated

• Revised conservative management requirements now specify, where applicable by indication, documented trial and failure of both medication therapy and physical measures.
• Removed the “tenderness over rotator cuff” criterion and separated distal clavicular excision and subacromial decompression/acromioplasty criteria for clarity.

Medical necessity criteria removed

• Diagnostic arthroscopy, debridement arthroscopy, and biceps tenodesis are no longer reviewed.

Revised pharmacy policies
Effective April 1, 2026

Advanced Therapies for Pharmacological Treatment of Pulmonary Arterial Hypertension, 5.01.522  PBC | Premera HMO
Medical necessity criteria updated

• Tadalafil and ambrisentan combination therapy criteria now clarify use for pulmonary arterial hypertension (World Health Organization [WHO] Group I).
• Winrevair (sotatercept-csrk) criteria now include individuals with WHO functional class IV.
• Tyvaso (treprostinil), Tyvaso DPI (treprostinil), and Yutrepia (treprostinil) criteria now include quantity limits.

Medical necessity criteria removed

• Ventavis (iloprost) has been discontinued by the manufacturer.

Antiemetic Medications, 5.01.662  PBC | Premera HMO
New policy

• Drugs for cancer‑related antiemetics and nausea/vomiting treatments moved from Medical Necessity Criteria for Pharmacy Edits, 5.01.605 to Antiemetic Medications, 5.01.662.
• Nereus (tradipitant) may be considered medically necessary for the prevention of vomiting induced by motion sickness when criteria are met.
• Bonjesta and Diclegis criteria revised to require documented inadequate response or intolerance to over‑the‑counter pyridoxine in combination with doxylamine.
• Generic doxylamine and pyridoxine delayed-release may be considered medically necessary for the treatment of nausea and vomiting of pregnancy when criteria are met.
• Akynzeo criteria revised to include a quantity limit of 1 capsule per fill.
• Sancuso criteria revised to include a quantity limit of 1 transdermal system per fill.

Bispecific Antibodies, 5.01.650  PBC | Premera HMO
Medical necessity criteria updated

• Imdelltra (tarlatamab‑dlle) and Ziihera (zanidatamab‑hrii) criteria revised to remove the requirement for an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1.
• Rybrevant (amivantamab‑vmjw) criteria revised for non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) exon 20 insertion mutations and disease progression on or after platinum‑based chemotherapy to specify use as a single agent.

Medical necessity criteria added

• Lunsumio Velo (mosunetuzumab‑axgb) SC may be considered medically necessary for the treatment of relapsed or refractory follicular lymphoma when criteria are met.
• Rybrevant Faspro (amivantamab and hyaluronidase‑lpuj) SC may be considered medically necessary for NSCLC with EGFR exon 20 insertion mutations when criteria are met.
• Rybrevant Faspro SC for the treatment of locally advanced or metastatic NSCLC with EGFR exon 19 deletions or exon 21 L858R substitution mutations may be considered medically necessary when criteria are met.

Length of approval criteria removed

• Non-formulary exception review no longer included in authorization criteria.

Drugs for Rare Diseases, 5.01.576  PBC | Premera HMO
Medical necessity criteria updated

• Cerezyme (imiglucerase) criteria revised to include treatment of Type 3 Gaucher disease and remove the age requirement.

Medical necessity criteria added

• Kygevvi (doxecitine and doxribtimine) may be considered medically necessary for the treatment of thymidine kinase 2 deficiency when criteria are met.
• Aqvesme (mitapivat) may be considered medically necessary for treatment of alpha- or beta-thalassemia when criteria are met.

IL-5 Inhibitors, 5.01.559  PBC | Premera HMO
Medical necessity criteria added

• Exdensur (depemokimab‑ulaa) may be considered medically necessary as add‑on maintenance therapy for severe asthma with an eosinophilic phenotype when criteria are met.
• Exdensur is now listed as a medication not to be used concurrently with Cinqair, Fasenra, and Nucala.

Length of approval criteria removed

• Non-formulary exception review no longer included in authorization criteria.

Immune Checkpoint Inhibitors, 5.01.591  PBC | Premera HMO
Medical necessity criteria updated

• Keytruda (pembrolizumab) and Keytruda Qlex (pembrolizumab and berahyaluronidase alfa-pmph) criteria revised to add a new indication, in combination with paclitaxel (with or without bevacizumab), for individuals with PD‑L1 positive (combined positive score greater than or equal to 1) platinum‑resistant epithelial ovarian, fallopian tube, or primary peritoneal carcinoma who have received 1 or 2 prior systemic therapies.

Length of approval criteria removed

• Non-formulary exception review no longer included in authorization criteria.

Medical Necessity Criteria for Custom Incentive and Open Formularies, 5.01.647  PBC | Premera HMO
Medical necessity criteria updated

• Rheumatoid arthritis criteria revised for Riabni, Ruxience, Truxima, Rituxan, and Rituxan Hycela to add Avtozma (tocilizumab‑anoh) and Tyenne (tocilizumab‑aazg) to the list of first‑line therapies.
• First‑ and second‑line criteria revised for adalimumab products in polyarticular juvenile idiopathic arthritis (PJIA) to require evidence of aggressive disease.
• Rheumatoid arthritis criteria revised for Kineret, Kevzara, Olumiant, and Simponi SC to add Avtozma (tocilizumab‑anoh) as a preferred alternative.
• Kevzara criteria revised for PJIA to change eligibility from age 18 or older to a minimum weight of 63 kg and add Avtozma as a preferred alternative.
• Orencia (abatacept) and Cimzia (certolizumab pegol) criteria revised in the treatment of PJIA and rheumatoid arthritis to add Avtozma (tocilizumab‑anoh) as a preferred alternative.
• Uveitis criteria revised for Infliximab (Janssen‑unbranded), Remicade, and Renflexis to require a trial of 1 preferred adalimumab product instead of all preferred products.
• Simponi (golimumab) SC criteria revised for active psoriatic arthritis to correct eligibility from a minimum weight of 15 kg to age 18 years or older.
• Simponi criteria for ulcerative colitis revised to change eligibility from age 18 years or older to a minimum weight of 15 kg.

Medical necessity criteria added

• Avtozma (tocilizumab-anoh) IV/SC may be considered medically necessary for the treatment of polyarticular juvenile idiopathic arthritis when criteria are met.
• Avsola (infliximab-axxq) IV and Inflectra (infliximab-dyyb) may be considered medically necessary for the treatment of non-infectious intermediate uveitis, posterior uveitis, or panuveitis when criteria are met.
• Otezla XR now included as a preferred alternative for psoriasis and psoriatic arthritis, replacing select biologic therapies across multiple indications.

Medical Necessity Criteria for Pharmacy Edits, 5.01.605  PBC | Premera HMO
Medical necessity criteria removed

• Drugs for cancer‑related antiemetics and nausea/vomiting treatments were moved from Medical Necessity Criteria for Pharmacy Edits, 5.01.605 to Antiemetic Medications, 5.01.662.
• Marinol (dronabinol capsules) no longer included in Cancer Related Antiemetics.
• Morgidox (doxycycline hyclate) and Avidoxy (doxycycline monohydrate) no longer included in Brand Oral Antibiotics and Their Generics.
• Quantity limit criteria moved from Medical Necessity Criteria for Pharmacy Edits, 5.01.605 to Drug Quantity Management, 5.01.656 for Dexcom and Freestyle Libre products, Opill, Suflave, ivermectin (including Stromectol), ketorolac, Lagevrio, and Paxlovid.
• Quantity limit criteria for InPen, Lynkuet, Prestalia, and Veozah from Medical Necessity Criteria for Pharmacy Edits, 5.01.605, as these limits are managed under Drug Quantity Management 5.01.656.

Medical necessity criteria added

• Omlonti (omidenepag isopropyl) may be considered medically necessary to reduce intraocular pressure in individuals with glaucoma when criteria are met.
• Nuzolvence (zoliflodacin) may be considered medically necessary for the treatment of uncomplicated urogenital gonorrhea caused by Neisseria gonorrhoeae when criteria are met.

Pharmacologic Treatment of Clostridioides Difficile, 5.01.631  PBC | Premera HMO
Medical necessity criteria added

• Fidaxomicin may be considered medically necessary for the treatment of Clostridioides difficile associated diarrhea when criteria are met.

Medical necessity criteria updated

• Zinplava (bezlotoxumab) criteria revised to lower the age requirement from 18 years or older to 1 year or older.

Pharmacologic Treatment of Seizures, 5.01.649  PBC | Premera HMO
Medical necessity criteria removed

• The following products are no longer listed: Carbatrol (carbamazepine); Celontin (methsuximide); Depakote DR, ER, and Sprinkle (divalproex); Dilantin products (phenytoin); Phenytek (phenytoin ER); Felbatol (felbamate); Keppra and Keppra XR (levetiracetam); Lamictal products (lamotrigine); Mysoline (primidone); Onfi tablets and suspension (clobazam); oxcarbazepine products (including Oxtellar XR and Trileptal); rufinamide; Tegretol products (carbamazepine); Topamax (topiramate); Zarontin capsule and solution (ethosuximide); and Zonegran (zonisamide).
• Vigpoder (vigabatrin) and Qudexy XR (topiramate extended‑release) are no longer marketed in the United States.

Medical necessity criteria added

• Generic lamotrigine orally disintegrating tablets now included in the policy with the same criteria as Lamictal ODT.
• Quantity limit per 30 days added for Motpoly XR (lacosamide extended‑release) and Sympazan (clobazam).
• Generic topiramate oral solution now included in the policy with the same criteria as Eprontia.
• Generic topiramate XR capsules (generic for Trokendi XR) now included in the policy with the same criteria as Trokendi XR.

Medical necessity criteria updated

• Lamictal ODT (lamotrigine orally disintegrating tablets) criteria revised to require a trial of generic lamotrigine immediate‑release tablets, or documentation that ODTs are clinically necessary (such as difficulty swallowing).
• Subvenite (lamotrigine oral suspension) criteria revised to require a trial of generic lamotrigine immediate‑release tablets, or documentation that the formulation is clinically necessary.
• Brand primidone criteria revised to include a quantity limit of 4 tablets per day.
• Trokendi XR (topiramate extended‑release capsules) criteria revised to clarify that inadequate response or intolerance applies to generic immediate‑release topiramate and topiramate ER sprinkle capsules and added a quantity limit per 30 days.
• Topiramate XR sprinkle capsules (generic for Qudexy XR) and brand Topiramate sprinkle capsules criteria revised to clarify that inadequate response or intolerance applies to generic immediate‑release topiramate, and added a quantity limit per 30 days.
• Eprontia (topiramate oral solution) criteria revised to clarify that the required trial is generic immediate‑release topiramate tablets.

Pharmacologic Treatment of Transthyretin-Mediated Amyloidosis, 5.01.593  PBC | Premera HMO
Medical necessity criteria updated

• Hereditary transthyretin-mediated amyloidosis treatment criteria for Amvuttra (vutrisiran), Onpattro (patisiran), and Wainua (eplontersen) revised to require documentation of a transthyretin (TTR) gene mutation or biopsy-confirmed amyloid deposition. Removed the requirement for 2 confirmatory diagnostic tests.
• Transthyretin amyloid cardiomyopathy (ATTR‑CM) treatment criteria for Amvuttra, Attruby, Vyndamax, and Vyndaqel revised to require documentation of a TTR gene mutation, biopsy‑confirmed amyloid deposition, or non‑biopsy nuclear scintigraphy. Removed the requirement for 2 confirmatory diagnostic tests.
• ATTR‑CM criteria for Amvuttra, Attruby, Vyndamax, and Vyndaqel revised to replace the restriction on implanted cardiac devices with a restriction on left ventricular assist devices. Added a note clarifying that wild‑type ATTR means no documented TTR gene mutations.
• Criteria for all drugs revised to allow prescribing by, or in consultation with, physicians experienced in treating ATTR amyloidosis (such as neurologists, cardiologists, or geneticists).

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  PBC | Premera HMO
Medical necessity criteria added

• Formulary‑specific note now included to Avsola and Inflectra for treatment of non‑infectious uveitis, clarifying that criteria do not apply to one open formulary plan and directing members to policy Medical Necessity Criteria for Custom Open Formulary, 5.01.647 when applicable.

Medical necessity criteria updated

• Filspari (sparsentan) and Tarpeyo (budesonide) criteria revised to clarify urine protein-to-creatinine (UPCR) thresholds (UPCR greater than or equal to 0.5 g/g or urine protein greater than or equal to 0.5 g/day) to align with 2025 Kidney Disease: Improving Global Outcomes guidelines.
• Uveitis criteria revised for Avsola, Inflectra, unbranded infliximab (Janssen), Remicade, and Renflexis to require trial of 1 preferred adalimumab product, rather than all preferred adalimumab products.

Pharmacotherapy of Perinatal/Infantile and Juvenile-Onset Hypophosphatasia (HPP), 5.01.573  PBC | Premera HMO
Medical necessity criteria updated

• Criteria language revised throughout policy from “at time of diagnosis” to “prior to 18 years of age.”
• Alkaline phosphatase (ALP) requirement revised from a single low result at diagnosis to persistently low age‑adjusted ALP levels (at least 2 separate tests) prior to 18 years of age.
• Skeletal radiograph examples revised to include rickets and recurrent metatarsal stress fractures, with atypical fractures clarified as atypical femoral fractures.
• Specialist requirement revised to remove reference to physicians specializing in hypophosphatasia or related disorders and specify a nephrologist or rheumatologist.
• Strensiq (asfotase alfa) criteria revised to add a dosage limit and require provider attestation allowing the specialty pharmacy to determine vial strengths for members weighing more than 40 kg to minimize waste.

Length of approval criteria updated

• Non-formulary exception review no longer included in authorization criteria.
• Initial authorization criteria revised to extend the approval period for all other reviews from 6 months to 12 months.

Therapeutic Radiopharmaceuticals in Oncology, 6.01.525  PBC | Premera HMO
Medical necessity criteria updated

• Pluvicto criteria revised to remove a duplicative reference to prior taxane‑based chemotherapy.
• Lutathera criteria revised to remove requirement that the individual has had disease progression while on octreotide long-acting release or lanreotide therapy.

Use of Granulocyte Colony-Stimulating Factors (G-CSF), 5.01.551  PBC | Premera HMO
Medical necessity criteria added

• Filkri (filgrastim‑laha), a biosimilar to Neupogen, may be considered medically necessary for infection prevention and management of severe neutropenia or myelosuppressive doses of radiation when criteria are met.
• Armlupeg (pegfilgrastim-unne), a biosimilar of Neulasta, may be considered medically necessary for infection prevention in individuals receiving myelosuppressive cancer therapy or radiation exposure.

Medical necessity criteria updated

• Nypozi (filgrastim-txid), Stimufend (pegfilgrastim-fpgk), Udenyca (pegfilgrastim-cbqv, and Udenyca Onbody (pegfilgrastim-cbqv) criteria now includes coverage for individuals acutely exposed to myelosuppressive radiation.

Length of approval criteria removed

• Non-formulary exception review no longer included in authorization criteria.

No updates this month.

No updates this month.

Added codes
Effective July 2, 2026

Prostate Artery Embolization, 7.01.55  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

37243

Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions, 2.01.543  PBC | Premera HMO
Now considered investigational.

G0465

Reconstructive Breast Surgery/Management of Breast Implants, 7.01.533  PBC | Premera HMO
Now requires review for cosmetic and prior authorization.

15769

Now requires review for cosmetic.

C1789

Effective June 5, 2026

Carelon Medical Benefits Management Radiation Oncology
Now reviewed by Carelon for medical necessity and prior authorization.

70472

Intracoronary Drug Delivery Balloon Procedures, 7.01.97  PBC | Premera HMO
Now considered investigational.

0913T, 0914T, C9610

Effective April 8, 2026

Mobile Cardiac Outpatient Telemetry and Implantable Loop Recorders, 2.01.510  PBC | Premera HMO
Site of Service Ambulatory Service Center (ASC): Select Surgical Procedures in Adults, 11.01.525  PBC | Premera HMO
Now requires review for medical necessity and prior authorization, in addition to review for site of service.

33285, E0616

Now requires review for medical necessity.

C1764

Effective April 1, 2026

Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms, 8.01.539  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

38230, S2142

Amniotic Membrane and Amniotic Fluid Injections, 7.01.583  PBC | Premera HMO
Now considered investigational.

Q4418, Q4419, Q4421, Q4422, Q4423, Q4424, Q4425, Q4426, Q4427, Q4428, Q4429, Q4435, Q4436, Q4437, Q4438, Q4439

Bioengineered Skin and Soft Tissue Substitutes, 7.01.582  PBC | Premera HMO
Now considered investigational.

A2040, A2041, A2042, A2043, A2044, A2045

Bispecific Antibodies, 5.01.650 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9601

Carelon Management Genetic Testing
Now reviewed by Carelon for medical necessity and prior authorization.

0628U, 0630U

Denosumab Biosimilars, 5.01.658 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

Q5161, Q5162

Gastric Electrical Stimulation, 7.01.522  PBC | Premera HMO
Now requires review for medical necessity.

64590

Gene Therapies for Rare Diseases, 5.01.642  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J3404

Gonadotropin Releasing Hormone (GnRH) Analogs, 5.01.625  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9003

Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia, 8.01.520  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

38232

Immune Checkpoint Inhibitors, 5.01.591  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9277

Immune Globulin Therapy, 8.01.503 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J1553

Laboratory Testing Investigational Services, 2.04.520  PBC | Premera HMO
Now considered investigational.

0614U, 0616U, 0617U, 0618U, 0619U, 0620U, 0621U, 0622U, 0623U, 0624U, 0625U, 0626U, 0627U, 0629U

Medical Necessity Criteria for Custom Incentive and Open Formularies, 5.01.647  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

Q5103, Q5156

Microprocessor-Controlled and Powered Prostheses and Orthoses for the Lower Limb, 1.04.503  PBC | Premera HMO
Now considered investigational.

L2221

Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9183

Myoelectric Prosthetic and Orthotic Components for the Upper Limb, 1.04.502  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

A8005, A8006

Non-covered Experimental/Investigational Services, 10.01.533  PBC | Premera HMO
Now non-covered.

C1743, G0680

Panniculectomy and Excision of Redundant Skin, 7.01.523  PBC | Premera HMO
Now requires review for cosmetic and prior authorization.

15877, 15878, 15879

Pharmacotherapy of Spinal Muscular Atrophy (SMA), 5.01.574  PBC | Premera HMO
Now requires review for medical necessity.

C9309

Prescription Digital Therapeutics, 13.01.500  PBC | Premera HMO
Prescription Digital Therapeutics for Substance Use Disorder, 5.01.643  PBC | Premera HMO
Now considered investigational.

A9294

Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.554  PBC | Premera HMO
Now requires review for medical necessity.

C8007, C8008, C8009, C8011, C8012, C8013

Transcatheter Aortic-Valve Implantation for Aortic Stenosis, 7.01.132  PBC | Premera HMO
Now considered investigational.

C8010

Revised codes
Effective July 1, 2026

Site of Service Ambulatory Service Center (ASC): Select Surgical Procedures for Adults, 11.01.525  PBC | Premera HMO
Upper Gastrointestinal Endoscopy (UGI) in Adults, 2.01.533  PBC | Premera HMO
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

43235, 43238, 43239, 43242

Effective June 5, 2026

Carelon Medical Benefits Management Radiation Oncology
Now reviewed by Carelon for medical necessity and prior authorization.

77436, 77437, 77438, 77439

Carpal Tunnel Release Surgical Techniques, 7.01.595  PBC | Premera HMO
Site of Service Ambulatory Service Center (ASC) Select Surgical or Diagnostic Procedures in Adults, 11.01.525  PBC | Premera HMO
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

29848, 64721

Effective April 1, 2026

Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers), 7.01.107  PBC | Premera HMO
Now considered investigational.

22867, 22868, 22869, 22870, C1821

Removed codes
Effective June 5, 2026

Electronic Brachytherapy for Nonmelanoma Skin Cancer, 8.01.62  PBC | Premera HMO
Now reviewed by Carelon for medical necessity and prior authorization.

77436, 77437, 77438, 77439

Effective April 1, 2026

Advanced Therapies for Pharmacological Treatment of Pulmonary Arterial Hypertension, 5.01.522  PBC | Premera HMO
No longer requires review.

Q4074

Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms, 8.01.539 PBC | Premera HMO
No longer requires review.

38232

Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.48  PBC | Premera HMO
Knee Arthroscopy in Adults, 7.01.549 PBC | Premera HMO
No longer requires review.

29870

Bispecific Antibodies, 5.01.650  PBC | Premera HMO
No longer requires review.

C9307

Shoulder Arthroscopy in Adults, 7.01.602  PBC | Premera HMO
No longer requires review.

29805, 29822, 29823, 29828

No updates this month.

No updates this month.

No updates this month.

No updates this month.

No updates this month.

No updates this month.

Effective April 8, 2026

Abdominal Wall Hernia in Adults, 7.01.600  PBC
New policy

• Open or laparoscopic abdominal hernia repair may be considered medically necessary when criteria are met.

Electrophysiology (EP) studies, 2.02.517  PBC
New policy

• Electrophysiology studies may be considered medically necessary when criteria are met.

Intravenous Iron Replacement Products, 5.01.630  PBC
New policy

• Feraheme (ferumoxytol), generic ferumoxytol, Injectafer (ferric carboxymaltose), and Monoferric (ferric derisomaltose) may be considered medically necessary for iron deficiency anemia in adults when criteria are met.

Shoulder Arthroscopy in Adults, 7.01.602  PBC
New policy

• Shoulder arthroscopy in adults may be considered medically necessary for the indications noted when criteria are met.
• Thermal capsulorrhaphy is considered not medically necessary.
• Shoulder arthroscopy is subject to review per Site of Service Ambulatory Service Center (ASC) Select Surgical Procedures, 11.01.525.

Shoulder Arthrotomy, 7.01.605  PBC
New policy

• Shoulder arthrotomy in adults may be considered medically necessary when criteria are met.

Site of Service Ambulatory Service Center (ASC): Select Surgical Procedures in Adults, 11.01.525  PBC
Medical necessity criteria added

• Shoulder Arthroscopy, 7.01.602 added to list of surgical or diagnostic procedures that require review for Site of Service ASC for Select Surgical or Diagnostic Procedures in Adults.

Added codes
Effective April 8, 2026

Abdominal Wall Hernia Repair in Adults, 7.01.600  PBC
Now requires review for medical necessity and prior authorization.

49591, 49593, 49595, 49613, 49615, 49617

Electrophysiology (EP) Studies, 2.01.517  PBC
Now requires review for medical necessity and prior authorization.

93609, 93613, 93619, 93620, 93621, 93622, 93624, 93653, 93654

Intravenous Iron Replacement Products, 5.01.630  PBC
Now requires review for medical necessity and prior authorization.

J1437, J1439, Q0138, Q0139

Shoulder Arthroscopy in Adults, 7.01.602  PBC
Now requires review for medical necessity and prior authorization, including review for site of service.

29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828

Shoulder Arthrotomy in Adults, 7.01.605  PBC
Now requires review for medical necessity and prior authorization.

20670, 20680, 23040, 23044, 23101, 23105, 23106, 23107, 23120, 23130, 23410, 23412, 23415, 23420, 23450, 23455, 23460, 23462, 23465, 23466, 23550, 23552, 23585, 23615, 23616, 23630, 23660, 23670, 23680

Site of Service Ambulatory Service Center (ASC): Select Surgical Procedures in Adults, 11.01.525  PBC
Now requires review for medical necessity and prior authorization, including review for site of service.

29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828