Medical Policy and Coding Updates January 2026

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 (examples: 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 the 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 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 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/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 aged 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 (examples include 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 including:
  • 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.

Effective for dates of service on and after January 1, 2026, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Radiology. 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.

• Combined computed tomography angiography (CTA) head and neck exam, which can be billed using code 70471. This replaces billing the two exams separately:
  • CTA Head (70496)
  • CTA Neck (70498)
• This update makes it easier to handle requests for combined head and neck imaging.
• The system will still allow separate requests for CTA Head and CTA Neck (same as now).
• This is a temporary step until full guidelines for this exam are ready (planned for late 2026).

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

Revised medical policies
Effective January 1, 2026

Focal Treatments for Prostate Cancer, 8.01.61 PBC | Premera HMO
Medical necessity criteria removed

• Irreversible electroporation for prostate cancer moved to Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, Lung, or Prostate, 6.01.68.

Gender Transition/Affirmation Surgery and Related Services, 7.01.557 PBC | Premera HMO
Medical necessity criteria updated

• For appearance revision without pain or functional issues:
  • Added wording, “which verifies or demonstrates,” to allow documentation in various forms showing expected improvement in appearance and reduction of gender dysphoria.
• Mental health recommendations:
  • Simplified criteria for evidence that gender incongruence/dysphoria and desire to transition have persisted over time.
  • Reduced required elements for mental health recommendations when requesting gender-affirming surgery/procedures more than two years after a prior authorization.

Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung, 6.01.68  PBC | Premera HMO
Title changed

• Policy title updated from Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung to Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung, or Prostate.

Medical necessity criteria moved

• Irreversible electroporation for prostate cancer moved from Focal Treatments for Prostate Cancer, 8.01.61 to Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, Lung, or Prostate, 6.01.68.

Protein Biomarkers for Diagnosis and Risk Assessment of Prostate Cancer, 2.04.514 PBC | Premera HMO
Medical necessity criteria added

• MiCheck prostate test is considered investigational.

Remote Electrical Neuromodulation for Migraines, 7.01.171  PBC | Premera HMO
Medical necessity criteria updated

• Updated remote electrical neuromodulation from investigational to medically necessary in adults for prevention of migraine when criteria are met.
• Treatment of acute migraine remains investigational.

Transcranial Magnetic Stimulation as a Treatment of Depression and other Psychiatric and Neurologic Disorders, 2.01.526  PBC | Premera HMO
Medical necessity criteria removed

• Removed statements excluding accelerated theta burst stimulation.
  • Stanford Neuromodulation Therapy and Stanford Accelerated Intelligent Neuromodulation Therapy protocols remain investigational.

Medical necessity criteria added

• Added electroencephalogram (EEG) brain mapping–guided transcranial magnetic stimulation (TMS) to investigational list.

Medical necessity criteria updated

• Medication failure requirement modified. Reasons can be stated for each medication or collectively.
• Expanded accelerated TMS coverage:
  • Removed hardship requirement for intensive courses.
  • Increased daily treatments to max five or 10 depending on TMS type, no increase in total treatments.
  • Concurrent functional magnetic resonance imaging (fMRI) or neuronavigation remains investigational.
• Updated maintenance TMS authorization:
  • Initial: up to 16 weeks (twice/week) or 26 weeks (≤one/week).
  • Reauthorization: up to 26 weeks if improvement is maintained.
• Clarified vagus nerve stimulation (VNS) and TMS policy:
  • Vagus nerve stimulation with TMS is not medically necessary for psychiatric conditions, except when starting or undergoing maintenance TMS before VNS activation.
• Added note: If VNS device is deactivated, intensive TMS may be medically necessary if criteria are met.

Vagus Nerve Stimulation, 7.01.593  PBC | Premera HMO
Medical necessity criteria updated

• Clarified VNS and TMS policy:
  • Vagus nerve stimulation with TMS is not medically necessary for psychiatric conditions, except when starting or undergoing maintenance TMS before VNS activation.
• Added note: If VNS device is deactivated, intensive TMS may be medically necessary if criteria met.
• Modified medication failure requirement: reasons can be stated for each medication or collectively.

New pharmacy policies
Effective January 1, 2026

Antipsychotics, 5.01.659  PBC | Premera HMO
New policy

• Criteria for all antipsychotics (second generation, “atypicals”) brands moved from Medical Necessity Criteria for Pharmacy Edits, 5.01.605 to Antipsychotics, 5.01.659
  • Brand clozapine, brand clozapine ODT, and Mezofy (aripiprazole) removed from criteria.
• Separate policy sections for Metallic formulary plans, Essentials formulary plans, and Open/Preferred/Select formulary plans.
• Formulary specific criteria for second generation antipsychotics created for Metallic formulary and Essentials formulary plans.

Inhaled Corticosteroids, 5.01.660  PBC | Premera HMO
New policy

• Criteria for inhaled corticosteroids moved from Medical Necessity Criteria for Pharmacy Edits, 5.01.605 to Inhaled Corticosteroids, 5.01.660.
• Criteria updated to include Fluticasone Ellipta as a qualifying product and removed Fluticasone Propionate Diskus as a qualifying product.

Medical Necessity Criteria for the Essentials Formulary, 5.01.657  PBC | Premera HMO
New policy

• Eliquis (apixaban) and Eliquis Sprinkle (apixaban) may be considered medically necessary when criteria are met.

Revised pharmacy policies
Effective January 1, 2026

BRAF and MEK Inhibitors, 5.01.589  PBC | Premera HMO
Medical necessity criteria updated

• Gomekli (mirdametinib) criteria updated to require individuals have tried and had an inadequate response or intolerance to Koselugo (selumetinib) first.
• Koselugo (selumetinib) criteria updated to include coverage for individuals aged one year and older.

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

• Arynta (lisdexamfetamine dimesylate) may be considered medically necessary for the treatment of binge eating disorder when criteria are met.
• Eurax (crotamiton) and Pruradik (crotamiton) may be considered medically necessary for the symptomatic treatment of pruritic skin when criteria are met.
• Marinol (dronabinol capsules) and Syndros (dronabinol oral solution) may be considered medically necessary for the treatment of nausea and vomiting associated with cancer or anorexia associated with weight loss in individuals with acquired immune deficiency syndrome when criteria are met.
• Brinsupri (brensocatib) may be considered medically necessary for the treatment of non-cystic fibrosis bronchiectasis when criteria are met.
• Soaanz (torsemide tablet) added to antihypertensive/diuretic drugs.
• Anzupgo (delgocitinib) may be considered medically necessary for the treatment of chronic hand eczema when criteria are met.
• Lynkuet (elinzanetant) added with a quantity limit of 60 capsules per 30 days.

Medical necessity criteria updated

• Nocdurna (desmopressin sublingual tablets) criteria updated to limit the prescribed quantity to one sublingual tablet per day.
• Alinia (nitazoxanide) and generic nitazoxanide criteria updated to include a daily dose limit.
• Sirturo (bedaquiline) criteria updated to include coverage for individuals aged two and older and weighing at least eight kg.
• Emend (aprepitant) criteria updated to include a quantity limit per fill.
• Linzess (linaclotide) criteria updated for the treatment of irritable bowel syndrome with constipation to include individuals aged seven years and older
• Arixtra (fondaparinux), Fragmin (dalteparin), and Lovenox (enoxaparin) criteria updated to require the individual has tried and had an inadequate response or intolerance to generic enoxaparin and generic fondaparinux.
• Kerendia (finerenone) criteria updated for the treatment of chronic kidney disease and heart failure limiting the prescribed quantity to one tablet per day.
• Cequa, Miebo, Restasis, Tryptyr, Vevye, and Xiidra criteria updated to add a prescribed quantity limit per 30 days.
• Palforzia criteria updated to limit the prescribed quantity to six capsules per day.
• Alkindi Sprinkle criteria updated to add a prescribed quantity limit per 30 days.
• Adapalene/benzoyl peroxide, Epiduo, and Epiduo Forte criteria updated to include quantity limits.
• Vyvanse criteria updated to include a prescribed quantity limit per 30 days.

Medical necessity criteria removed

• Aczone removed from Brand Topical Acne or Rosacea Products.
• Accuretic, Lotensin HCT, Lotrel, Prestalia, Vaseretic, and Zestoretic removed from ACEI Combinations, Brand.
• Adderall, Adderall XR, Adzenys ER, Adzenys XR-ODT, Desoxyn, Dexedrine, Evekeo, and Zenzedi removed from ADHD Drugs, Brands.
• Azor, brand levamlodipine, Caduet, Cardizem, Cardizem CD, Cardizem LA, Conjupri, Exforge, Exforge HCT, Lotrel, Norvasc, Prestalia, Procardia XL, Sular, Tiazac, Tribenzor, and Verelan PM removed from Calcium Channel Blockers.
• Klaron removed from Topical Sebolonrrheic Dermatitis Agents, Brand.
• Accupril, Altace, Epaned, Lotensin, Qbrelis, Vasotec, and Zestril removed from ACEIs, Brand.
• Generic pyrimethamine removed from Antiparasitic Agents.
• Consensi removed from Combination Medications (Misc.).
• Atacand, Avapro, Benicar, Cozaar, Diovan, Edarbi, Micardis, Tekturna, and Valsartan solution removed from Angiotensin II Receptor Blockers (ARBs), Brand.
• Acanya and Cleocin T and PR benzoyl peroxide 7% wash removed from Brand Topical Acne or Rosacea Products.
• Celebrex and Dolobid removed from Brand Oral NSAIDs.
• Lopressor removed from Beta Blockers, Oral.
• Criteria for all Antipsychotics (Second Generation, “Atypicals”), Brands moved from Medical Necessity Criteria for Pharmacy Edits, 5.01.605 to Antipsychotics, 5.01.659.
• Criteria for inhaled corticosteroids moved from Medical Necessity Criteria for Pharmacy Edits, 5.01.605 to Inhaled Corticosteroids, 5.01.660.

Migraine and Cluster Headache Medications, 5.01.503 PBC | Premera HMO
Medical necessity criteria updated

• Criteria for Amerge (naratriptan), Frova (frovatriptan), Imitrex (sumatriptan), Maxalt (rizatriptan), Maxalt MLT (rizatriptan), Relpax (eletriptan), Tosymra (sumatriptan), Zomig (zolmitriptan) tablets, and Zomig (zolmitriptan) 5 mg nasal spray updated to remove requirement to use generic triptans first.
• Quantity for Elyxyb (celecoxib oral solution) updated from 18 bottles per 30 days to 12 bottles per 28 days.
• Migranal (dihydroergotamine) nasal spray criteria updated to remove requirement to use generic dihydroergotamine nasal spray first.

Medical necessity criteria added

• Generic ergotamine-caffeine tablets and Migergot (ergotamine-caffeine) may be considered medically necessary for the acute treatment of migraine headaches when criteria are met.

Medical necessity criteria removed

• Ergomar (ergotamine) criteria removed.

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

• Inrebic (fedratinib), Lynparza (olaparib), Retevmo (selpercatinib) criteria updated to include a quantity limit.

Medical necessity criteria added

• Blenrep (belantamab mafodotin-blmf) may be considered medically necessary for the treatment of relapsed or refractory multiple myeloma when criteria are met.
• Cosmegen (dactinomycin) may be considered medically necessary when criteria are met.

Medical necessity criteria removed

• Kisqali Femara Co-Pack removed as drug was withdrawn from the market.
• Casodex (bicalutamide), Eulexin (flutamide), Nilandron (nilutamide), generic nilutamide, and quantity limits moved to Drug Quantity Management, 5.01.656.

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

• Removed reference to Preferred formulary (Formulary ID: 6064; Rx Plan G3) as it is no longer available.

Medical necessity criteria updated

• Lupkynis (voclosporin) and Benlysta (belimumab) SC/IV criteria updated to clarify that the medication will not be used concurrently with Gazyva (obinutuzumab).

Selective Estrogen Receptor Modulators and Down Regulators, 5.01.618  PBC | Premera HMO
Medical necessity criteria added

• Inluriyo (imlunestrant) may be considered medically necessary for the treatment of estrogen receptor-positive, human epidermal growth factor receptor 2-negative, ESR1- mutated advanced or metastatic breast cancer when criteria are met.

Medical necessity criteria removed

• Arimidex (anastrozole), Aromasin (exemestane), Evista (raloxifene), and quantity limits moved to Drug Quantity Management, 5.01.656.

Spravato (esketamine) Nasal Spray, 5.01.609  PBC | Premera HMO
Medical necessity criteria updated

• Criterion added confirming no current or past bipolar disorder and no history of manic or hypomanic episodes.
• Substance use criterion updated to require remission or complete abstinence for at least one month, with agreement to remain abstinent.
• Option added for temporary increase in treatment frequency to twice weekly if depression worsens during maintenance.
• Clarified that improvement during maintenance can be shown by symptom documentation or standardized depression rating scales.
• Modified medication failure requirement: reasons for failure can be stated for each medication individually or collectively for all failed medications.

Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517 PBC | Premera HMO
Medical necessity criteria updated

• Revlimid (lenalidomide) to require that the individual has tried and had an inadequate response or intolerance to generic lenalidomide for all indications.

Effective January 1, 2026

Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis, 2.04.127
Policy archived

• Policy archived due to this diagnostic procedure being standard of care.

No updates this month.

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 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 January 1, 2026

Amniotic Membrane and Amniotic Fluid, 5.01.583  PBC | Premera HMO
Now considered investigational.

Q4398, Q4399, Q4400, Q4401, Q4402, Q4403, Q4404, Q4405, Q4406, Q4407, Q4408, Q4409, Q4410, Q4411, Q4412, Q4413, Q4414, Q4415, Q4416, Q4417, Q4420

Antibody-Drug Conjugates, 5.01.582  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9326

Automated Percutaneous and Percutaneous Endoscopic Discectomy, 7.01.18 PBC | Premera HMO

Image-Guided Minimally Invasive Decompresson for Spinal Stenosis, 7.01.126  PBC | Premera HMO
Now considered investigational.

62330, 62331

Bariatric Surgery, 7.01.516  PBC | Premera HMO
Now considered investigational.

43889

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

Q4431, Q4432, Q4433

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

C9307

Carelon Benefit Management Guidelines, Advanced Imaging and Site of Care
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

70336, 70450, 70471, 70473, 70491, 70480, 70486, 70490, 70496, 70498, 70540, 70544, 70547, 70551, 71250, 71271, 71275, 71550, 71555, 72125, 72128, 72131, 72141, 72146, 72148, 72159, 72191, 72192, 72195, 72198, 73200, 73206, 73218, 73221, 73225, 73700, 73706, 73721, 73725, 74150,  74174, 74175, 74176, 74181, 74185, 74263, 75635, 77078

Carelon Benefit Management Guidelines, Genetic Testing
Now requires review for medical necessity and prior authorization.

0605U, 0611U, 0612U, 0613U, 81354, 81524

Carpal Tunnel Release: Surgical Techniques, 7.01.595  PBC | Premera HMO
Now considered investigational.

64728

Cooling Devices Used in the Outpatient Setting, 1.01.538  PBC | Premera HMO
Now requires review for medical necessity.

C9810, C9817

Coronary Angiography for Known or Suspected Coronary Artery Disease in Adults, 2.02.507  PBC | Premera HMO
Now requires review for medical necessity.

C7568, C7570

Drug Testing in Pain Management and Substance Use Disorder Treatment Settings, 2.04.513  PBC | Premera HMO
Now considered investigational.

0603U

Electronic Brachytherapy for Nonmelanoma Skin Cancer, 8.01.62  PBC | Premera HMO
Now considered investigational.

77436, 77437, 77438, 77439

Gene Therapies for Cerebral Andrenoleukodystrophy, 6.01.534  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J3387

Hearing Aids (Excludes Implantable Devices), 1.01.528  PBC | Premera HMO
Benefit managed only

92628, 92629, 92631, 92632, 92634, 92635, 92636, 92637, 92638, 92639, 92641, 92642

Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain and Other Conditions, 7.01.574  PBC | Premera HMO
Now considered investigational.

0988T, 0989T

Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, Lung, or Prostate, 6.01.68  PBC | Premera HMO
Now considered investigational.

47384, 55877

Laboratory Testing Investigational Services, 2.04.520  PBC | Premera HMO
Now non-covered.

0600U, 0601U, 0602U, 0606U, 0607U, 0608U, 0609U

Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomy in Adults, 7.01.551  PBC | Premera HMO
Now requires review for medical necessity, in addition to current review for site of service and prior authorization.

63032

Medical Necessity Criteria for Pharmacy Edits, 5.01.605  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J1073

Deep Brain Stimulation, 7.01.63  PBC | Premera HMO
Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain, 7.01.574PBC | Premera HMO
Gastric Electrical Stimulation, 7.01.522  PBC | Premera HMO
Occipital Nerve Stimulation, 7.01.125  PBC | Premera HMO
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy, 7.01.143PBC | Premera HMO
Sacral Nerve Neuromodulation Stimulation, 7.01.69  PBC | Premera HMO
Spinal Cord and Dorsal Root Ganglion Stimulation, 7.01.546 PBC | Premera HMO
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.554PBC | Premera HMO
Vagus Nerve Stimulation, 7.01.593  PBC | Premera HMO
Now requires review for medical necessity.

C1607

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

0990T, 0991T, 0992T, 0993T, 0994T, 0995T, 0996T, 0997T, 0998T, 0999T, 1000T, 1001T, 1002T, 1004T, 1005T, 1006T, 1007T, 1008T, 1009T, 1010T ,1011T, 1013T, 1014T, 1015T, 1016T, 1017T, 1018T, 27458, 27713, 52443, 75577, 94470, C9761, E0446

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

E0420, E0244, E0245, 97007, 97008, 97009

Percutaneous Coronary Intervention, Angioplasty, Non-Emergent in Adults, 2.01.508  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

92930, 92945

Now requires review for medical necessity.

C7569, C7571

Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome, 2.01.106  PBC | Premera HMO
Now considered investigational.

64567

Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease, 7.01.594  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

37254, 37255, 37256, 37257, 37258, 37259, 37260, 37261, 37263, 37264, 37265, 37266, 37267, 37268, 37269, 37270, 37271, 37272, 37273, 37274, 37275, 37276, 32727, 37278, 37280, 37281, 37282, 37283, 37284, 37285, 37286, 37287, 37288, 37289, 37290, 37291, 37292, 37293, 37294, 37295, 37296, 37297, 37298, 37299

Now considered investigational.

37262, 37279

Pharmacologic Treatment of Epidermolysis Bullosa, 5.01.635  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J3389

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9256

Preventive Care Services, 10.01.523  PBC | Premera HMO
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

77046, 77047, 77048, 77049

Now covered as part of the standard benefit.

G0023, G0024

Spravato (esketamine) Nasal Spray, 5.01.609  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J0013

Surgical Treatments for Lymphedema and Lipedema, 7.01.567  PBC | Premera HMO
Now considered investigational.

1019T

Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation for Benign Prostatic Hyperplasia, 2.01.544  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

52597

Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

Q5160

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

Effective January 1, 2026

Microwave Tumor Ablation, 7.01.033  PBC | Premera HMO
No longer considered investigational. Now requires review for medical necessity and prior authorization.

0944T

No longer requires review for medical necessity. Now requires review for investigational and prior authorization.

60660, 60661

Remote Electrical Neuromodulation for Migraines, 7.01.171  PBC | Premera HMO
No longer considered investigational. Now requires review for medical necessity and prior authorization.

A4540

No longer requires review for medical necessity. Now requires review for investigational and prior authorization.

60660, 60661

Removed codes

Effective January 1, 2026

Antibody-Drug Conjugates, 5.01.582  PBC | Premera HMO
Code Terminated

C9306

Bariatric Surgery, 7.01.516  PBC | Premera HMO
Code Terminated

C9784

Carelon Benefit Management Guidelines, Advanced Imaging
Code Terminated

0042T

Carelon Benefit Management Guidelines, Genetic Testing
Code Terminated

0033U, 0131U, 0132U, 0135U, 0508U, 0509U, 0544U

Carelon Benefit Management Guidelines, Radiation Oncology
Code Terminated

77385, 77386, 77014

Electronic Brachytherapy for Nonmelanoma Skin Cancer, 8.01.62  PBC | Premera HMO
Code Terminated

0394T

Evaluation of Biomarkers for Alzheimers Disease, 2.04.521  PBC | Premera HMO
Code Terminated

0361U, 0551U

Image-Guided Minimally Invasive Decompresson for Spinal Stenosis, 7.01.126  PBC | Premera HMO
Code Terminated

0275T

Immune Globulin Therapy, 8.01.503  PBC | Premera HMO

Site of Service: Drugs and Biologic Agents, 11.01.523  PBC | Premera HMO
Code Terminated

J1572

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

J0889

Microwave Tumor Ablation, 7.01.133  PBC | Premera HMO
Code Terminated

C9751

Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
Code Terminated

J9019, J9245

Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis, 2.04.127  PBC | Premera HMO
No longer requires review.

0330U, 0505U, 0557U, 81513, 81514, 81515

Non-Covered Experimental and Investigational Services, 10.01.533  PBC | Premera HMO
Code Terminated

0619T, 0623T, 0624T, 0625T, 0626T

Non-Covered Services, 10.01.517  PBC | Premera HMO
No longer requires review.

G0023, G0024

Code Terminated

0663T

Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitues) Used with Autologous Bone Marrow, 8.01.52  PBC | Premera HMO
No longer requires review.

0263T, 0264T, 0265T, 38241

Percutaneous Coronary Intervention, Angioplasty, Non-Emergent in Adults, 2.02.508  PBC | Premera HMO
Code Terminated

92921, 92925, 92929, 92934, 92938, 92944

Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome, 2.01.106  PBC | Premera HMO
Code Terminated

0720T

Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease, 7.01.594  PBC | Premera HMO
Code Terminated

7220, 37221, 37222, 37223, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234, 37235

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  PBC | Premera HMO
Code Terminated

C9305

Spravato (esketamine) Nasal Spray, 5.01.609  PBC | Premera HMO
Code Terminated

S0013

Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation for Benign Prostatic Hyperplasia, 2.01.544  PBC | Premera HMO
Code Terminated

0421T

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 (examples include 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

• 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.
  • High risk Human Papillomavirus (hrHPV)-based screening triggers including immediate high-resolution anoscopy for hrHPV 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.

Effective January 1, 2026

Site of Service: Drugs and Biologic Agents, 11.01.523  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J1743, J9289

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.

Effective January 1, 2026

Federal Employee Program (FEP) Prior Authorization Requirement Updates

FEP 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 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

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