Medical Policy and Coding Updates

Effective April 8, 2026

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

• Policy title expanded 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.
• Implantable loop recorders are subject to review per Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525.

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, 2.02.510 added as an included policy to indicate that implantable loop recorders only require review for Site of Service ASC for Select Surgical or Diagnostic Procedures in Adults.

Effective March 4, 2026

Electrophysiology (EP) Studies, 2.02.517  PBC | Premera HMO
New policy

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

Endovascular Stent Grafts for Abdominal Aortic Aneurysms, 7.01.601  PBC | Premera HMO
New policy

• The use of endoprostheses approved by the Food and Drug Administration (FDA) as a treatment of abdominal aortic aneurysms may be considered medically necessary when criteria are met.

Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570  PBC | Premera HMO
Medical necessity criteria updated

• Amondys 45 (casimersen), Duvyzat (givinostat), Exondys 51 (eteplirsen), Viltepso (vitolarsen), and Vyondys 53 (golodirsen) re-authorization criteria updated to require that documentation is provided that the individual is ambulatory without needing an assistive device (for example, cane, walker, and wheelchair).

Shoulder Arthrotomy in Adults, 7.01.605  PBC | Premera HMO
New policy

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

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

• Changed 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 (UGI) Endoscopy for Adults, 2.01.533 added to list of surgical or diagnostic procedures that require review for Site of Service ASC for Select Surgical or Diagnostic Procedures.

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

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

Medical necessity criteria added

• Site of Service Ambulatory Service Center (ASC) Select Surgical Procedures, 11.01.525 criteria added.

Effective February 6, 2026

Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses, 1.01.506  PBC | Premera HMO
Medical necessity criteria added

• Second cranial orthosis as a treatment of persistent plagiocephaly after two months of use of the initial cranial orthosis may be considered medically necessary when criteria are met.

Gastroesophageal Reflux Surgery in Adults, 7.01.604  PBC | Premera HMO
New policy

• Laparoscopic esophagogastric fundoplication may be considered medically necessary when criteria are met.

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

• Criteria updates requiring that the tumors express PD-L1 (at least one):
  • Yervoy (ipilimumab) for the treatment of esophageal squamous cell carcinoma (ESCC).
  • Opdivo (nivolumab) and Opdivo Qvantig (nivolumab and hyaluronidase-nvhy) for the treatment of gastric cancer, gastroesophageal junction cancer, and esophageal adenocarcinoma.
  • Opdivo Qvantig for the first-line treatment of unresectable advanced or metastatic ESCC.

Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
Medical necessity criteria added

• Generic clofarabine and Clolar (clofarabine) for the treatment of relapsed or refractory acute lymphoblastic leukemia after at least two prior regimens in individuals aged one to 21 years.
• Ixempra (ixabepilone) when used in combination with capecitabine for the treatment of metastatic or locally advanced breast cancer when criteria are met.

Pharmacotherapy of Thrombocytopenia, 5.01.566  PBC | Premera HMO
Medical necessity criteria added

• WinRho SDF (Rh_o (D) Immune Globulin (Human)) for treatment of immune thrombocytopenia when criteria are met.
• WinRho SDF (Rh_o (D) Immune Globulin (Human)) for suppression of Rh isoimmunization in non-sensitized, Rh_o(D)-negative (D-negative) women with a Rh-incompatible pregnancy when criteria are met.

Shoulder Arthroscopy in Adults, 7.01.602  PBC | Premera HMO
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.

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

• Shoulder arthroscopy in adults is subject to review per Site of Service Ambulatory Service Center (ASC) Select Surgical Procedures.

Revised medical policies
Effective February 1, 2026

Focal Treatments for Prostate Cancer, 8.01.541  PBC | Premera HMO
Policy renumbered

• This policy replaces Focal Treatments for Prostate Cancer, 8.01.61, which is now deleted.
• Irreversible electroporation technique, Nanoknife, moved to Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, Lung, or Prostate, 6.01.68.

Upper Gastrointestinal (UGI) Endoscopy in Adults, 2.01.533  PBC | Premera HMO
Medical necessity criteria updated

• UGI criteria updated to include treatment in individuals who were diagnosed with pernicious anemia within the last year.

Revised pharmacy policies
Effective February 1, 2026

Antibody-Drug Conjugates, 5.01.582  PBC | Premera HMO
Medical necessity criteria added

• Padcev (enfortumab vedotin-ejfv) for the treatment of muscle invasive bladder cancer who are ineligible for cisplatin-containing chemotherapy when used in combination with pembrolizumab or pembrolizumab and berahyaluronidase alfa-pmph, as neoadjuvant treatment and then continued after cystectomy as adjuvant treatment.

Medical necessity criteria updated

• Padcev (enfortumab vedotin-ejfv) for the treatment of locally advanced or metastatic urothelial cancer criteria updated to include combination with pembrolizumab and berahyaluronidase alfa-pmph.

Antipsychotics, 5.01.659  PBC | Premera HMO
Medical necessity criteria updated

• Symbyax (fluoxetine-olanzapine) criteria updated to require the individual tried fluoxetine-olanzapine and had an inadequate response or intolerance.
• Vraylar (cariprazine) for the treatment of bipolar depression criteria updated to require the individual tried quetiapine, lurasidone, or olanzapine-fluoxetine combination and had an inadequate response or intolerance.

BCR-ABL Kinase Inhibitors, 5.01.518  PBC | Premera HMO
Medical necessity criteria updated

• Danziten (nilotinib) criteria updated to add prescribed quantity limit per 30 days.
• Phyrago (dasatinib) criteria updated to include coverage for pediatric individuals one year of age and older with Ph+ CML in chronic phase, and pediatric individuals one year of age and older with newly diagnosed Ph+ ALL in combination with chemotherapy.

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

• Epkinly may be considered medically necessary in combination with lenalidomide and rituximab for the treatment of relapsed or refractory follicular lymphoma when criteria are met.

Bruton Tyrosine Kinase Inhibitors, 5.01.590  PBC | Premera HMO
Title Changed

• Policy title changed from Bruton Kinase Inhibitors to Bruton Tyrosine Kinase Inhibitors.

Medical necessity criteria updated

• Jaypirca (pirtobrutinib) for the treatment of relapsed or refractory chronic lymphocytic leukemia or small lymphocytic lymphoma criteria updated to remove requirement of two prior lines of therapy including a B-cell lymphoma 2 inhibitor.

Medical necessity criteria added

• Rhapsido (remibrutinib) for the treatment of chronic spontaneous urticaria who remain symptomatic despite at least 2 H1 antihistamines in high doses (at least twice normal dosing and up to four times normal dosing) or to maximum tolerated dose.

Drugs for Weight Management, 5.01.621  PBC | Premera HMO

Medical necessity criteria updated

• Wegovy (semaglutide) injection criteria updated to include Wegovy tablets in list of medications not to be used concurrently with.

Medical necessity criteria added

• Wegovy (semaglutide) tablets to reduce the risk of major adverse cardiovascular (CV) events in adults with established CV disease and either obesity or overweight; and to reduce excess body weight and maintain weight reduction long term in adults with obesity, or in adults with overweight in the presence of at least one weight-related comorbid condition.

Dupixent (dupilumab), 5.01.575  PBC | Premera HMO
Medical necessity criteria updated

• Dupixent (dupilumab)for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) criteria updated to include that it is not be used in combination with Tezspire (tezepelumab-ekko).
• Chronic idiopathic urticaria criteria updated to remove reference of failed to respond to one H1 inhibitor used in combination with any one or more of the following: an H2 antihistamine, oral corticosteroids, or leukotriene modifiers as this treatment combination is no longer recommended and added a restriction on use in combination with Rhapsido (remibrutinib).

Epidermal Growth Factor Receptor (EGFR) Inhibitors, 5.01.603  PBC | Premera HMO
Medical necessity criteria updated

• Zegfrovy (sunvozertinib) for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) criteria updated to include has progressed on or after platinum-based chemotherapy.

Folate Antimetabolites, 5.01.617  PBC | Premera HMO
Medical necessity criteria updated

• Alimta (pemetrexed), Pemrydi RTU (pemetrexed), Axtle (pemetrexed), brand pemetrexed (Avyxa-unbranded), brand pemetrexed (Hospira-unbranded), brand pemetrexed (Novaplus-unbranded), Pemfexy (pemetrexed), brand pemetrexed (Accord-unbranded), brand pemetrexed (BluePoint Laboratories), brand pemetrexed (Sandoz-unbranded), brand pemetrexed (Teva-unbranded), brand pemetrexed ditromethamine criteria updated to include in combination with osimertinib and platinum-based chemotherapy for the first-line treatment of adult individuals with locally advanced or metastatic NSCLC whose tumors have EGFR exon 19 deletions or exon 21 L858R mutations.

Medical necessity criteria updated

• Axtle (pemetrexed) criteria updated to include new indication in combination with pembrolizumab and platinum chemotherapy, for the initial treatment of metastatic non-squamous NSCLC, with no EGFR or ALK genomic tumor aberrations.

Medical necessity criteria removed

• Removed criteria for Jylamvo (methotrexate), Otrexup (methotrexate).
• Removed criteria for Trexall (methotrexate) and quantity limit moved to Drug Quantity Management, 5.01.656.

HER2 Inhibitors, 5.01.514  PBC | Premera HMO
Medical necessity criteria updated

• Hernexeos (zongertinib) criteria updated to remove the requirement for Eastern Cooperative Oncology Group performance status of zero or one.

Medical necessity criteria added

• Hyrnuo (sevabertinib) for the treatment of locally advanced or metastatic, non-squamous NSCLC whose tumors have human epidermal growth factor receptor 2 (HER2/ERBB2) tyrosine kinase domain activating mutations, and who received a prior systemic therapy.
• Enhertu (fam-trastuzumab deruxtecan-nxki) when used in combination with pertuzumab as first-line treatment of unresectable or metastatic HER2-positive (IHC 3+ or ISH+) breast cancer.
• Perjeta (pertuzumab) for the treatment of unresectable or metastatic HER2-positive (IHC 3+ or ISH+) breast cancer when used in combination with Enhertu (fam-trastuzumab deruxtecan-nxki) as first line treatment.

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

• Cinqair (reslizumab), Fasenra (benralizumab), and Nucala (mepolizumab) criteria for asthma management updated to allow for the use of oral or systemic corticosteroids for asthma exacerbations, to allow for a blood eosinophil count greater than or equal to 150 cells/mcL, and to allow for exceptions for individuals unable to discontinue oral or systemic corticosteroids for eosinophil testing.
• Fasenra and Nucala criteria for eosinophilic granulomatosis with polyangiitis management updated from an absolute eosinophil count of at least 1500 cells/microL to at least 1000 cells/microL.
• Nucala criteria for the treatment of CRSwNP updated to include it will not be used in combination with Tezspire (tezepelumab-ekko).

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

• Generic albendazole criteria updated to add a dose limit of 400 mg twice daily.
• Camzyos, Corlanor, generic ivabradine, Kerendia, and Verquvo criteria updated to limit use to being prescribed by a cardiologist.
• InPen criteria updated to include a quantity limit of one pen per 365 days.
• Prestalia (amlodipine/perindopril) criteria updated to include a quantity limit of 30 tablets per 30 days.

Medical necessity criteria added

• Vostally (ramipril oral solution) added to Angiotensin Converting Enzyme Inhibitors for treatment in individuals with an inadequate response or intolerance to generic ramipril.
• Sdamlo (amlodipine solution) added to Calcium Channel Blockers for treatment in individuals who have tried and failed two generic calcium channel blockers due to an inadequate response or intolerance.
• Myqorzo (aficamten) for the treatment of symptomatic New York Heart Association class II-III obstructive hypertrophic cardiomyopathy when criteria are met.
• Atmeksi (methocarbamol oral suspension) added to Muscle Relaxants in individuals whp have had an inadequate response or intolerance to generic methocarbamol.
• Pilocarpine 1.25% ophthalmic solution to Ophthalmic Cholinergic Agonists for the treatment of presbyopia when criteria are met.
• Vyscoxa (celecoxib oral suspension) added to Brand Oral NSAIDs in individuals who have tried and had an inadequate response or intolerance to generic celecoxib.

Medical necessity criteria removed

• Clovique (trientine hydrochloride) removed as the product has been discontinued.

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

• Imaavy (nipocalimab-aahu), Rystiggo (rozanolixizumab-noli), Vyvgart (efgartigimod alfa-fcab), Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) criteria updated to add Ultomiris to list of medications not to be used concurrently with.

Medical necessity criteria added

• Voyxact (sibeprenlimab-szsi) to reduce proteinuria in adults with primary immunoglobulin A nephropathy at risk for disease progression.
• Uplizna (inebilizumab-cdon) for the treatment of generalized myasthenia gravis.

Prostate Cancer Targeted Therapies, 5.01.544  PBC | Premera HMO
Medical necessity criteria updated

• Akeega (niraparib and abiraterone acetate) criteria updated to add a new indication for the treatment of deleterious or suspected deleterious BRCA2-mutated metastatic castration-sensitive prostate cancer when used in combination with prednisone.

Xolair (omalizumab), 5.01.513  PBC | Premera HMO
Medical necessity criteria updated

• Chronic idiopathic urticaria criteria updated to remove reference of failed to respond to one H1 inhibitor used in combination with any one or more of the following: an H2 antihistamine, oral corticosteroids, or leukotriene modifiers and added a restriction on use in combination with Dupixent (dupilumab) and Rhapsido (remibrutinib).
• Xolair criteria for the treatment of CRSwNP updated to add that it will not be used in combination with Tezspire (tezepelumab-ekko).

No updates this month.

Effective February 1, 2026

Focal Treatments for Prostate Cancer, 8.01.61
Policy deleted

• This policy is now deleted and replaced by Focal Treatments for Prostate Cancer, 8.01.541.

Added codes
Effective April 8, 2026

Mobile Cardiac Outpatient Telemetry and Implantable Loop Recorders, 2.01.510  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

Site of Service Ambuatory 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

Effective March 4, 2026

Electrophysiology (EP) Studies, 2.02.517  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

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

Endovascular Stent Grafts for Abdominal Aortic Aneurysms, 7.01.601  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708, 34710, 34711, 34717, 34718, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848

Non-covered Services and Procedures, 10.01.517  PBC | Premera HMO
Now non-covered.

0751T, 0752T, 0754T, 0755T, 0757T, 0758T, 0759T, 0760T, 0761T, 0762T, 0763T

Shoulder Arthrotomy in Adults, 7.01.605  PBC | Premera HMO
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 for Adults, 11.01.525  PBC | Premera HMO
Now requires review for medical necessity, in addition to current review for site of service and prior authorization.

43235, 43238, 43239, 43242

Effective February 6, 2026

Cosmetic and Reconstructive Services, 10.01.514  PBC | Premera HMO
Requires review for medical necessity and prior authorization.

21086, V2623, V2629

Gastroesophageal Reflux Surgery in Adults, 7.01.604  PBC | Premera HMO
Requires review for medical necessity and prior authorization.

43280, 43281, 43282

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

J9027, J9207

Pharmacotherapy of Thrombocytopenia, 5.01.566  PBC | Premera HMO
Requires review for medical necessity and prior authorization.

J2791

Shoulder Arthroscopy in Adults, 7.01.602  PBC | Premera HMO
Requires review for medical necessity and prior authorization.

29805, 29806, 29807, 29819, 29820-29828

Site of Service Ambulatory Service Center (ASC) Select Surgical Procedures, 11.01.525  PBC | Premera HMO
Requires review for site of service, in addition to current review for medical necessity and prior authorization.

29805, 29806, 29807, 29819-29828

Effective February 1, 2026

Focal Treatments for Prostate Cancer, 8.01.541  PBC | Premera HMO
Now considered investigational.

0582T, 0655T, 0738T, 0739T, 0950T, 55880

Revised codes
Effective March 4, 2026

Upper Gastrointestinal (UGI) Endoscopy for 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

Removed codes
Effective February 1, 2026

Drug Testing in Pain Management and Substance Abuse Disorder, 2.04.513  PBC | Premera HMO
No longer requires review.

0603U

Medical Necessity Criteria for Pharmacy Edits, 5.01.605  PBC | Premera HMO
Code terminated.

S0189

Effective February 6, 2026

Routine Test Management Policies
New policies

• Fifty routine test management (RTM) policies (see list below).
• The policies are intended to support claims editing for laboratory services, not prior authorization, and exclude genetic testing, which will continue to be reviewed through  Carelon Medical Benefits Management.
  • These policies are managed through claims edits to handle straightforward, rule-based criteria (for example, diagnosis matching and frequency limits), not complex clinical decisions.

Allergen Testing, 15.01.001  PBC | Premera HMO
Biomarker Testing for Autoimmune Rheumatic Disease, 15.01.040  PBC | Premera HMO
Biomarkers for Myocardial Infarction and Chronic Heart Failure, 15.01.034  PBC | Premera HMO
Bone Turnover Markers Testing, 15.01.011  PBC | Premera HMO
Celiac Disease Testing, 15.01.031  PBC | Premera HMO
Coronavirus Testing in the Outpatient Setting, 15.01.014  PBC | Premera HMO
Diagnosis of Idiopathic Environmental Intolerance, 15.01.036  PBC | Premera HMO
Diagnostic Testing of Influenza, 15.01.018  PBC | Premera HMO
Diagnostic Testing of Iron Homeostasis & Metabolism, 15.01.030  PBC | Premera HMO
Epithelial Cell Cytology in Breast Cancer Risk Assessment, 15.01.033  PBC | Premera HMO
Evaluation of Dry Eyes, 15.01.007  PBC | Premera HMO
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing, 15.01.039  PBC | Premera HMO
Fecal Calprotectin Testing in Adults, 15.01.012  PBC | Premera HMO
Flow Cytometry, 15.01.002  PBC | Premera HMO
Folate Testing, 15.01.024  PBC | Premera HMO
Gamma-glutamyl Transferase, 15.01.021  PBC | Premera HMO
General Inflammation Testing, 15.01.019  PBC | Premera HMO
Helicobacter Pylori Testing, 15.01.032  PBC | Premera HMO
Human Immunodeficiency Virus (HIV), 15.01.027  PBC | Premera HMO
Identification Of Microorganisms Using Nucleic Acid Probes, 15.01.016  PBC | Premera HMO
Immune Cell Function Assay, 15.01.010  PBC | Premera HMO
Immunohistochemistry, 15.01.005  PBC | Premera HMO
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies, 15.01.035  PBC | Premera HMO
In Vitro Chemoresistance and Chemosensitivity Assays, 15.01.038  PBC | Premera HMO
Intracellular Micronutrient Analysis, 15.01.041  PBC | Premera HMO
Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease, 15.01.051  PBC | Premera HMO
Lyme Disease Testing, 15.01.008  PBC | Premera HMO
Metabolite Markers of Thiopurines Testing, 15.01.009  PBC | Premera HMO
Nerve Fiber Density Testing, 15.01.022  PBC | Premera HMO
Onychomycosis Testing, 15.01.037  PBC | Premera HMO
Pancreatic Enzyme Testing for Acute Pancreatitis, 15.01.025  PBC | Premera HMO
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing, 15.01.006  PBC | Premera HMO
Pathogen Panel Testing, 15.01.043  PBC | Premera HMO
Prescription Medication and Illicit Drug Testing in the Outpatient Setting, 15.01.046  PBC | Premera HMO
Prostate Biopsy Specimen Analysis, 15.01.045  PBC | Premera HMO
Salivary Hormone Testing, 15.01.028  PBC | Premera HMO
Serum Biomarker Testing for Multiple Sclerosis and related Neurologic Disease, 15.01.052  PBC | Premera HMO
Serum Testing for Evidence of Mild Traumatic Brain Injury, 15.01.023  PBC | Premera HMO
Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease, 15.01.013  PBC | Premera HMO
Serum Tumor Markers for Malignancies, 15.01.042  PBC | Premera HMO
Testing For Alpha-1 Antitrypsin Deficiency, 15.01.048  PBC | Premera HMO
Testing for Vector-borne Infections, 15.01.026  PBC | Premera HMO
Testing of Homocysteine Metabolism-Related Conditions, 15.01.049  PBC | Premera HMO
Testosterone, 15.01.017  PBC | Premera HMO
Therapeutic Drug Monitoring for 5-Fluorouracil, 15.01.044  PBC | Premera HMO
Thyroid Disease Testing, 15.01.003  PBC | Premera HMO
Urinary Tumor Markers for Bladder Cancer, 15.01.050  PBC | Premera HMO
Urine Culture Testing for Bacteria, 15.01.015  PBC | Premera HMO
Venous and Arterial Thrombosis Risk Testing, 15.01.047  PBC | Premera HMO
Vitamin B12 And Methylmalonic Acid Testing, 15.01.029  PBC | Premera HMO

No updates this month.

Effective February 6, 2026

Drug Testing in Pain Management and Substance Abuse Disorder, 2.04.513
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis, 2.04.26
Intracellular Micronutrient Testing, 2.04.73
Nutrient/Nutrional Panel Testing, 2.04.136
Policies deleted

• Drug Testing in Pain Management and Substance Abuse Disorder, 2.04.513 deleted and replaced with routine test management (RTM) policy Prescription Medication and Illicit Drug Testing in the Outpatient Setting, 15.01.046.
• Fecal Analysis in the Diagnosis of Intestinal Dysbiosis, 2.04.26 deleted and replaced with  RTM policy Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing, 15.01.039.
• Intracellular Micronutrient Testing, 2.04.73 deleted and replaced with RTM policy Intracellular Micronutrient Analysis, 15.01.041.
• Nutrient/Nutrional Panel Testing, 2.04.136 deleted and replaced with RTM policy Intracellular Micronutrient Analysis, 15.01.041.

No updates this month.

Effective March 4, 2026

Laryngeal Injection for Vocal Cord Augmentation, 2.01.541  PBC
Title changed

• Changed title from Laryngeal Injection for Vocal Cord Augmentation Augmentation to Office-based Laryngeal Procedures.

Medical necessity cariteri updated

• Additional procedures and diagnoses added; policy scope aligned with procedures performed in the office setting.

Effective February 6, 2026

Drug Testing in Pain Management and Substance Use Disorder Treatment Settings, 2.04.522  PBC | Premera HMO
Policy renumbered

• This policy replaces Drug Testing in Pain Management and Substance Use Disorder Treatment Settings, 2.04.513, which is now deleted.

Intracellular Micronutrient Testing, 2.04.525  PBC | Premera HMO
Policy renumbered

• This policy replaces Intracellular Micronutrient Testing, 2.04.73, which is now deleted.

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis, 2.04.524  PBC | Premera HMO
Policy renumbered

• This policy replaces Fecal Analysis in the Diagnosis of Intestinal Dysbiosis, 2.04.26, which is now deleted.

Nutrient/Nutritional Panel Testing, 2.04.523  PBC | Premera HMO
Policy renumbered

• This policy replaces Nutrient/Nutritional Panel Testing, 2.04.136, which is now deleted.

Effective February 6, 2026

Drug Testing in Pain Management and Substance Use Disorder Treatment Settings, 2.04.513
Policy deleted

• This policy is replaced with Drug Testing in Pain Management and Substance Use Disorder Treatment Settings, 2.04.522.

Intracellular Micronutrient Testing, 2.04.73
Policy renumbered

• This policy is replaced with Intracellular Micronutrient Testing, 2.04.525.

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis, 2.04.26
Policy renumbered

• This policy is replaced with Fecal Analysis in the Diagnosis of Intestinal Dysbiosis, 2.04.524.

Nutrient/Nutritional Panel Testing, 2.04.136
Policy renumbered

• This policy is replaced with Nutrient/Nutritional Panel Testing, 2.04.523.

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 Ambulartory 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 Repain 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 Ambulartory 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

Revised codes
Effective February 6, 2026

Adcetris (brentuximab vedotin), 5.21.019  FEP
Requires review for prior authorization.

J9042

Aranesp (darbepoetin alfa), 5.85.001  FEP
Requires review for prior authorization.

J0881

Briumvi (ublituximab-xiiy), 5.60.057  FEP
Requires review for prior authorization.

J2329

Darzalex Faspro (daratumumab and hyaluronidase-fihj), 5.21.147  FEP
Requires review for prior authorization.

J9144

Enhertu (fam-trastuzumab deruxtecan-nxki), 5.21.138  FEP
Requires review for prior authorization.

J9358

GamaSTAN S/D (IGIM), 5.20.002  FEP
Requires review for prior authorization.

J1560

Hyaluronic Acid Derivatives, 5.75.009  FEP
Requires review for prior authorization.

J7318, J7323, J7326, J7328, J7320, J7321, J7322, J7327, J7324, J7331, J7325, J7332, J7329

Imaavy (nipocalimab-aahu), 5.85.066  FEP
Requires review for prior authorization.

C9305

IVIG (intravenous immunoglobulin), 5.20.003  FEP
Requires review for prior authorization.

J1552, J1554, J1556, J1555, J1572, J1569, J1566, J1561, J1557, J1568, J1576, J1459

Kadcyla (ado-trastuzumab emtansine), 5.21.032  FEP
Requires review for prior authorization.

J9354

Keytruda (pembrolizumab), 5.21.050  FEP
Requires review for prior authorization.

J9271

Neupogen Granix Nivestym Nypozi Releuko Zarxio, 5.85.010  FEP
Requires review for prior authorization.

Q5148

Ocrevus (ocrelizumab), 5.60.028  FEP
Requires review for prior authorization.

J2350

Opdivo (nivolumab), 5.21.053  FEP
Requires review for prior authorization.

J9299

Ophthalmic VEGF Inhibitors, 5.90.026  FEP
Requires review for prior authorization.

Q5150, Q5149, Q5153, Q5147, Q5155

Perjeta (pertuzumab), 5.21.020  FEP
Requires review for prior authorization.

J9306

Rystiggo (rozanolixizumab-noli), 5.85.050  FEP
Requires review for prior authorization.

J9333

SCIG Immune Globulin (subcutaneous immunoglobulin), 5.20.008  FEP
Requires review for prior authorization.

J1551, J1575, J1559, J1575, J1558

Soliris (eculizumab), 5.85.011  FEP
Requires review for prior authorization.

Q5151

Spinraza (nusinersen), 5.75.015  FEP
Requires review for prior authorization.

J2326

Stelara (ustekinumab), 5.90.004  FEP
Requires review for prior authorization.

Q9999, Q5098, Q9996, Q9997, Q9998, Q5099, Q5137, Q5138, Q5139, Q5100

Tepezza (teprotumumab-trbw), 5.30.064  FEP
Requires review for prior authorization.

J3241

Trastuzumab, 5.21.006  FEP
Requires review for prior authorization.

Q5146, Q5113

Tysabri (natalizumab), 5.60.013  FEP
Requires review for prior authorization.

J2350

Ultomiris (ravulizumab-cwvz), 5.85.033  FEP
Requires review for prior authorization.

J1303

Xgeva (denosumab), 5.30.018  FEP
Requires review for prior authorization.

J0897, Q5158, Q5136, Q5157, Q5159

Zilbrysq (zilucoplan), 5.85.054  FEP
Requires review for prior authorization.

J3490

Zymfentra (infliximab-dyyb), 5.50.039  FEP
Requires review for prior authorization.

J1748