Medical Policy and Coding Updates

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, 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, 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.

Medical necessity criteria added

• Upper Gastrointestinal (UGI) Endoscopy for Adults, 2.01.533 added to a 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

• Title changed 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 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.

Effective January 2, 2026

Abdominal Wall Hernia in Adults, 7.01.600  PBC | Premera HMO
New policy

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

C3 and C5 Complement Inhibitors, 5.01.571  PBC | Premera HMO
Medical necessity criteria updated

• Bkemv (eculizumab-aeeb) and Soliris (eculizumab) updated from a preferred to a non-preferred product.
• Zilbrysq (zilucoplan) myasthenia gravis criteria updated to require trial with a preferred brand product first.

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

• Ogivri (trastuzumab-dkst) updated from a non-preferred to a preferred product.
• Trastuzumab products (Herceptin, Herceptin Hylecta, Hercessi, Herzuma, and Ontruzant) updated to require trial with all preferred trastuzumab products.

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

• Adalimumab-aaty (Yuflyma unbranded), Yuflyma (adalimumab-aaty), Avsola (infliximab-axxq), and Riabni (rituximab-arrx) updated from a non-preferred to a preferred product.
• Cyltezo (adalimumab-adbm) and Zymfentra (infliximab-dyyb) updated from a preferred to a non-preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria updated to require that the individual has had an inadequate response or intolerance to the preferred products for new starts.

Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502  PBC | Premera HMO
Medical necessity criteria updated

• Riabni (rituximab-arrx) updated from a non-preferred to a preferred product.
• Non-preferred rituximab products, Rituxan and Rituxan Hycela, updated to require trial with all preferred rituximab products.

Pharmacotherapy of Arthropathies, 5.01.550  PBC | Premera HMO
Medical necessity criteria updated

• Adalimumab-aaty (Yuflyma unbranded), Yuflyma (adalimumab-aaty), and Avsola (infliximab-axxq) updated from a non-preferred to a preferred product.
• Cyltezo (adalimumab-adbm) updated from a preferred to a non-preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria updated to require that the individual has had an inadequate response or intolerance to the preferred products for new starts.

Pharmacologic Treatment of Psoriasis, 5.01.629  PBC | Premera HMO
Medical necessity criteria updated

• Adalimumab-aaty (Yuflyma unbranded), Yuflyma (adalimumab-aaty), Yuflyma (adalimumab-aaty) and Avsola (infliximab-axxq) updated from a non-preferred to a preferred product.
• Cyltezo (adalimumab-adbm) and Zymfentra (infliximab-dyyb) updated from a preferred to a non-preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria updated to require that the individual has had an inadequate response or intolerance to the preferred products for new starts.

Pharmacologic Treatment of Psoriatic Arthritis, 5.01.645  PBC | Premera HMO
Medical necessity criteria updated

• Adalimumab-aaty (Yuflyma unbranded), Yuflyma (adalimumab-aaty) and Avsola (infliximab-axxq) updated from a non-preferred to a preferred product.
• Cyltezo (adalimumab-adbm) and Zymfentra (infliximab-dyyb) updated from a preferred to a non-preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria updated to require that the individual has had an inadequate response or intolerance to the preferred products for new starts.

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  PBC | Premera HMO
Medical necessity criteria updated

• Adalimumab-aaty (Yuflyma unbranded), Yuflyma (adalimumab-aaty), and Avsola (infliximab-axxq) updated from a non-preferred to a preferred product.
• Cyltezo (adalimumab-adbm) and Zymfentra (infliximab-dyyb) updated from a preferred to a non-preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria updated to require that the individual has had an inadequate response or intolerance to the preferred products for new starts.
• Omvoh (mirikizumab-mrkz) IV/SC updated from a preferred to a non-preferred product in sections two and three.

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

• Adalimumab-aaty (Yuflyma unbranded), Yuflyma (adalimumab-aaty), and Avsola (infliximab-axxq) updated from a non-preferred to a preferred product.
• Cyltezo (adalimumab-adbm) and Zymfentra (infliximab-dyyb) updated from a preferred to a non-preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria updated to require that the individual has had an inadequate response or intolerance to the preferred products for new starts.
• Imaavy (nipocalimab-aahu) criteria updated to require trial with a preferred brand product first.
• Rystiggo (rozanolixizumab-noli) criteria brand step therapy requirement updated to remove Soliris (eculizumab) and add Epysqli (eculizumab-aagh) as an option.
• Fabhalta (iptacopan) and Filspari (sparsentan) criteria updated to require trial with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) and your urine protein-to-creatinine ratio is still 1.5 g/g or higher, or intolerance to an ACE inhibitor or ARB because of side effects or intolerance.

Rituximab: Non-oncologic and Miscellaneous Uses, 5.01.556  PBC | Premera HMO
Medical necessity criteria updated

• Adalimumab-aaty (Yuflyma unbranded), Yuflyma (adalimumab-aaty), Riabni (rituximab-arrx) and Avsola (infliximab-axxq) updated from a non-preferred to a preferred product.
• Cyltezo (adalimumab-adbm) updated from a preferred to a non-preferred product.
• Updated non-preferred rituximab products, Rituxan and Rituxan Hycela, to require trial with all preferred rituximab products.

Skilled Nursing Facility (SNF): Admission, Continued Stay, and Transition of Care Guideline, 11.01.510 PBC | Premera HMO
Medical necessity criteria added

• Service requirements and clinical appropriateness added to criteria.
• Admission conditions and continued stay conditions added to criteria.

Transcatheter Tricuspid Valve Repair or Replacement, 2.02.518  PBC | Premera HMO
New policy

• Transcatheter tricuspid edge-to-edge repair and transcatheter tricuspid valve replacement are considered investigational for all indications.

Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders, 5.01.620  PBC | Premera HMO
Medical necessity criteria added and updated

• Beovu (brolucizumab-dbll), Eylea (aflibercept), Eylea HD (aflibercept), Macugen (pegaptanib), and Susvimo (ranibizumab) criteria updated to require that the individual has had an inadequate response or intolerance to two preferred products for new starts.

Effective January 1, 2026

Auditory Brainstem Implant, 7.01.83 PBC | Premera HMO
Cochlear Implant, 7.01.586  PBC | Premera HMO
Hearing Aids (Excludes Implantable Devices), 1.01.528  PBC | Premera HMO
Implantable Bone-Conduction and Bone-Anchored Hearing Aids, 7.01.547  PBC | Premera HMO
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids, 7.01.84  PBC | Premera HMO
Medical necessity criteria added

• Benefit Application updated to include new Washington state mandate, effective January 1, 2026:
  • Coverage for minors under 18 requires medical clearance within the past six months.
  • Clearance must come from either an otolaryngologist (initial hearing loss evaluation) or a licensed physician confirming no significant clinical change since that evaluation.

Effective for dates of service on and after January 1, 2026, site of service will be reviewed for advanced imaging services using the following criteria and administered through Carelon Medical Benefits Management, Inc. Site of Care for Advanced Imaging.

Hospital Outpatient Site of Care (HOPD)

HOPD is considered medically necessary when:

• Ancillary services are required and not available at freestanding centers in the same geographic area, including:
  • Moderate sedation, deep sedation, or general anesthesia
  • Obstetrical or perinatology observation
  • Support for establishing or maintaining intravenous access in patients with prior access difficulty
  • Transfer or positioning assistance for bedbound patients or those with stage three to four decubitus ulcers
  • Additional nursing or facility resources to support patients on contact or airborne precautions
  • Rapid response capability for patients with high-risk medical conditions (for example, contrast allergy, implantable cardiac devices, ventilator dependence, and high risk of airway compromise)
• Specialized resources are needed and not available or infrequently performed at freestanding centers in the same area, such as:
  • Modalities requiring specialized hardware, software, or imaging protocols
  • Expertise from subspecialty radiologists not available in the community, including pediatric radiology
  • Technology such as open or large bore magnetic resonance imaging (MRI), for patients with claustrophobia, or equipment suitable for patients with very high body mass index
• Continuity of care considerations apply, including:
  
  • Follow-up imaging previously performed at the same HOPD when technique consistency is needed for comparison
  • Imaging required for pre-procedural planning when the procedure is scheduled at the same hospital
  • Clinically significant delays in care would be expected if imaging were redirected outside the HOPD

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 December 4, 2025

Botulinum Toxins, 5.01.512  PBC | Premera HMO
Medical necessity criteria updated

• Botox (onabotulinumtoxinA), Daxxify (daxibotulinumtoxinA-lanm), Dysport (abobotulinumtoxinA), Myobloc (rimabotulinumtoxinB), and Xeomin (incobotulinumtoxinA) updated throughout the policy to indicate that these drugs are not to be used concurrently.

Negative Pressure Wound Therapy (NPWT) Devices in Adults, 1.01.508  PBC | Premera HMO
New policy

• NPWT devices are considered medically necessary when criteria are met.

Revised medical policies
Effective December 1, 2025

Automated Pancreas Device Systems, 1.01.30  PBC | Premera HMO
Title change

• Title changed from Artificial Pancreas Device Systems to Automated Insulin Delivery Systems.

Medical necessity criteria added

• Use of an FDA approved hybrid closed-loop system may be considered medically necessary when criteria are met.

Balloon Dilation of the Eustachian Tube, 7.01.606  PBC | Premera HMO
Policy renumbered

• This policy replaces Balloon Dilation of the Eustachian Tube, 7.01.158, which is now deleted.

Medical necessity criteria updated

• Balloon dilation of the eustachian tube is considered not medically necessary when policy criteria are not met.

Carpal Tunnel Release Surgical Treatments, 7.01.595  PBC | Premera HMO
Medical necessity criteria updated

• Provocative tests now included along with Carpal Tunnel Symptom Scale (CTS)-6 evaluation tool score for added simplicity.

Isolated Small Bowel Transplant, 7.03.511  PBC | Premera HMO
Policy renumbered

• This policy replaces Isolated Small Bowel Transplant, 7.03.04, which is now deleted.

Medical necessity criteria updated

• Small bowel transplant using living donors is considered not medically necessary when policy criteria are not met.

Knee Arthroscopy in Adults, 7.01.549  PBC | Premera HMO
Medical necessity criteria updated

• Clarified for meniscal tear if aged 50 and older that the imaging is “done within 12 months prior to surgery” and shows the absence of severe arthritis.

Medical necessity criteria removed

• Removed arthroscopic excision of popliteal cyst criteria.

Leadless Cardiac Pacemakers, 2.02.515  PBC | Premera HMO
Medical necessity criteria added

• Aveir VR single-chamber (right ventricular) transcatheter pacing system may be considered medically necessary when criteria are met.
• Micra AV single-chamber (right ventricular) transcatheter pacing system may be considered medically necessary when criteria are met.
• Aveir AR single-chamber (right atrial) transcatheter pacing system is considered investigational for all indications.

Liver Transplant and Combined Liver-Kidney Transplant, 7.03.509  PBC | Premera HMO
Investigational criteria updated

• Additional indications (unresectable colorectal liver metastases, hepatic epithelioid hemangioendothelioma, hepatic adenomas, and intrahepatic cholangiocarcinoma) added to investigational criteria for liver transplant.

Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions, 2.01.543  PBC | Premera HMO
Investigational criteria updated

• Additional indications added to investigational criteria for use of platelet-rich plasma.

Revised pharmacy policies
Effective December 1, 2025

Denosumab Products, 5.01.658  PBC | Premera HMO
Medical necessity criteria added

• Bosaya (denosumab-kyqq), and Enoby (denosumab-qbde) may be considered medically necessary for the treatment of osteoporosis when criteria are met.
• Aukelso (denosumab-kyqq), and Xtrenbo (denosumab-qbde) may be considered medically necessary for the prevention of skeletal-related events in an individual with bone metastases from solid tumors when criteria are met.

Drugs for Weight Management, 5.01.621  PBC | Premera HMO
Medical necessity criteria added

• Generic liraglutide 18 mg/3 mL pen may be considered medically necessary for the treatment of overweight or obesity when criteria are met.

Medical necessity criteria updated

• Saxenda (liraglutide) criteria updated to require trial with generic liraglutide 18 mg/3 mL pen.

Gene Therapies for Rare Diseases, 5.01.642  PBC | Premera HMO
Medical necessity criteria added

• Papzimeos (zopapogene imadenovec-drba) may be considered medically necessary for the treatment of recurrent respiratory papillomatosis when criteria are met

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

• Libtayo (cemiplimab) may be considered medically necessary for the adjuvant treatment of cutaneous squamous cell carcinoma at high risk of recurrence after surgery and radiation when criteria are met.
• Tecentriq (atezolizumab) and Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) may be considered medically necessary for the maintenance treatment of extensive-stage small cell lung cancer when used in combination with Zepzelca (lurbinectedin).

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

• Brand econazole added to Antifungals, Topical Brand.
• Enbumyst (bumetanide nasal spray) added to Antihypertensive/Diuretic.

Medical necessity criteria updated

• Correction made to the quantity limit for Blujepa (gepotidacin).

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

• Revuforj (revumenib) may be considered medically necessary for the treatment of acute myeloid leukemia when criteria are met.
• Gazyva (obinutuzumab) may be considered medically necessary for the treatment of active lupus nephritis when criteria are met.
• Zepzelca (lurbinectedin) may be considered medically necessary for the treatment of extensive-stage small cell lung cancer when criteria are met.

Pharmacologic Treatment of Atopic Dermatitis, 5.01.628 PBC | Premera HMO
Medical necessity criteria updated

• Opzelura (ruxolitinib) criteria updated from 12 years of age and older to two years of age and older.

Medical necessity criteria added

• Zoryve (roflumilast) 0.05% cream may be considered medically necessary for the treatment of atopic dermatitis when criteria are met.

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

• Pyquvi (deflazacort) and Jaythari (deflazacort) added to oral corticosteroids.

Pharmacologic Treatment of Interstitial Lung Disease, 5.01.555 PBC | Premera HMO
Medical necessity criteria added

• Jascayd (nerandomilast) may be considered medically necessary for the treatment of idiopathic pulmonary fibrosis when criteria are met.

Pharmacologic Treatment of Phenylketonuria, 5.01.585  PBC | Premera HMO
Medical necessity criteria added

• Zelyvsia (sapropterin) may be considered medically necessary for the treatment of individuals with phenylketonuria when criteria are met.
• Zelyvsia (sapropterin) added as a prerequisite drug an individual must try prior to brand Kuvan (sapropterin), Palynziq, and Sephience.
• Palynziq, Sephience criteria updated to prevent use in combination with Zelyvsia.

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

• Subvenite (lamotrigine) may be considered medically necessary for the adjunctive treatment of partial-onset seizures, primary generalized tonic-clonic seizures, or seizures associated with Lennox-Gastaut syndrome when criteria are met.
• Subvenite (lamotrigine) may be considered medically necessary for the treatment of bipolar depression and for the maintenance treatment of bipolar I disorder when criteria are met.

Pharmacotherapy of Cushing’s Disease and Acromegaly, 5.01.548  PBC | Premera HMO
Medical necessity criteria added

• Palsonify (paltusotine) may be considered medically necessary for the treatment of acromegaly when criteria are met.

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  PBC | Premera HMO
Medical necessity criteria updated

• Rinvoq (upadacitinib) Crohn’s disease criteria updated to clarify that a TNF blocker trial is not required if the treatment is considered clinically inadvisable.
• Rinvoq (upadacitinib) ulcerative colitis criteria updated to clarify that a TNF blocker trial is not required if the treatment is considered clinically inadvisable and the individual has tried at least one systemic therapy.

Thymic Stromal Lymphopoietin (TSLP) Inhibitors, 5.01.627  PBC | Premera HMO
Medical necessity criteria updated

• Tezspire (tezepelumab-ekko) criteria updated to include treatment of certain individuals with chronic rhinosinusitis with nasal polyposis.

No updates this month.

Effective December 1, 2025

Balloon Dilation of the Eustachian Tube, 7.01.158
Policy deleted

• This policy is replaced with Balloon Dilation of the Eustachian Tube, 7.01.606.

Isolated Small Bowel Transplant, 7.03.04
Policy deleted

• This policy is replaced with Isolated Small Bowel Transplant, 7.03.511.

Added codes
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 January 2, 2026

Abdominal Wall Hernias, 7.01.600  PBC | Premera HMO
Requires review for medical necessity and prior authorization.

49591, 49593, 49595, 49613, 49615, 49617, 49659

Pharmacotherapy of Cushing's Disease and Acromegaly, 5.01.548  PBC | Premera HMO
Requires review for medical necessity and prior authorization.

J1932

Transcatheter Tricuspid Valve Repair or Replacement, 2.02.518  PBC | Premera HMO
Considered investigational.

0569T, 0570T, 0646T

Effective December 4, 2025

Leadless Cardiac Pacemakers, 2.02.515  PBC | Premera HMO
Considered investigational.

0798T, 0799T, 0800T

Negative Pressure Wound Therapy (NPWT) Devices, 1.01.508  PBC | Premera HMO
Requires review for medical necessity and prior authorization.

97605, 97606, 97607, 97608, A6550, A7000, A7001, A9272, E2402, K0743, K0744, K0745, K0746

Effective December 1, 2025

Balloon Dilation of the Eustachian Tube, 7.01.606  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

69705, 69706

Isolated Small Bowel Transplant, 7.03.511  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

44135, 44136, S2152

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

Q5104, Q5121, Q5144

Revised codes
Effective March 4, 2026

Upper Gastrointestinal (UGI) Endoscopy for Adults, 2.01.533  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 December 1, 2025

Balloon Dilation of the Eustachian Tube, 7.01.158  PBC | Premera HMO
No longer requires review.

69705, 69706

Implantable Cardioverter Defibrillator (ICD), 7.01.44  PBC | Premera HMO
No longer requires review.

93260, 93261, 93282-93284, 93289

Isolated Small Bowel Transplant, 7.03.04  PBC | Premera HMO
No longer requires review.

44135, 44136, S2152

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
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.

Removed codes
Effective December 1, 2025

Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
No longer requires review.

J9245

Effective March 4, 2026

Laryngeal Injection for Vocal Cord Augmentation, 2.01.541  PBC
Title changed

• Title changed from Laryngeal Injection for Vocal Cord Augmentation Augmentation to Office-based Laryngeal Procedures.

Medical necessity criteria updated

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

Effective January 2, 2026

High-Resolution Anoscopy, 2.01.539  PBC
Medical necessity criteria added

• Indications added:
  • Symptom-driven and therapeutic indications including rectal bleeding, anal pain, fistula, trauma, foreign body retrieval, hemorrhoid treatment (rubber band ligation), and post-treatment surveillance for anal carcinoma.
  • hrHPV-based screening triggers including immediate high-resolution anoscopyfor high risk (hr) Human Papillomavirus (HPV) -positive results (including HPV16+) and specific cytology/hrHPV combinations, even when cytology is negative for intraepithelial lesion or malignancy.
• Contraindications added:
  • Patient-related limitations including the inability to tolerate the exam due to discomfort, anxiety, or apprehension.
  • Clinical safety concerns including significant active bleeding or presence of a friable mass that could be damaged, bleed, or irritated by the rigid anoscope.

No updates this month.

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 January 1, 2026

Federal Employee Program (FEP) Prior Authorization Requirement Updates

Federal Employee Program will require review for medical necessisty and prior authorization for hip, knee, and spine surgeries for standard and basic plan types for both federal and postal plans.

Added codes
Effective January 1, 2026

Artificial Intervertebral Disc: Lumbar Spine, 7.01.589  PBC
Cervical Spine Surgeries: Discectomy, Laminectomy, and Fusion in Adults, 7.01.560  PBC
Interspinous Fixation (Fusion) Devices, 7.01.591  PBC
Laminectomy in Adults, 7.01.551  PBC
Lumbar Spinal Fusion in Adults, 7.01.542  PBC
Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy,
Non-covered Experimental/Investigational Services, 10.01.533  PBC
Now requires review for medical necessity and prior authorization for Standard and Basic plans.

22533, 22534, 22551, 22552, 22554, 22558, 22585, 22600, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22853, 22854, 22859, 63005, 63012, 63017, 63020, 63030, 63035, 63042, 63044, 63045, 63047, 63048, 63052, 63053, 63056, 63057, 63185, 63190, 63091, 63267, 63272, C1831, C9757

Hip Arthroplasty in Adults, 7.01.573  PBC
Now requires review for medical necessity and prior authorization for Standard and Basic plans.

27100, 27105, 27110, 27111, 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, 27140, 27146, 27147, 27151

Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions, 7.01.607  PBC
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.48  PBC | FEP
Knee Arthroplasty in Adults, 7.01.550  PBC
Meniscal Allografts and Other Meniscal Implants, 7.01.15  PBC
Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty, 7.01.144  PBC
Now requires review for medical necessity and prior authorization for Standard and Basic plans.

27400, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 27427, 27428, 27429; 27430; 27435; 27437; 27438; 27440, 27441; 27442, 27443, 27445, 27446, 27447, 27448, 27450, 27454, 27455, 27457, 27465, 27466, 27468, 27470, 27472, 27475, 27477, 27479, 27485, 27486, 27487, 27495, 27496, 27497, 27498, 27499

Surgical Treatment of Femoroacetabular Impingement, 7.01.118  FEP
Surgical Treatment of Femoroacetabular Impingement, 7.01.592  PBC
Now requires review for medical necessity and prior authorization for Standard and Basic plans.

29914, 29915, 29916, 27299

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