Medical Policy and Coding Updates November 2025

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
Drug/medical necessity criteria added:

• WinRho solvent detergent formulation (Rh_o (D) immune globulin (human)) for treatment of immune thrombocytopenia when criteria are met.
• WinRho solvent detergent formulation (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 is 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 is 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, 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 hospital outpatient department (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:

• Negative pressure wound therapy devices are considered medically necessary when criteria are met.

Effective November 15, 2025

Effective for dates of service on and after November 15, 2025, 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.

Updates by section

Imaging of the Brain

• Specification of magnetic resonance imaging (MRI) for amyloid therapy monitoring.
• Expansion to remove intervals and include other amyloid therapies.
• Updated for non-acute trauma to align with American College of Radiology (ACR) Appropriate Use Criteria (AUC) recommendations, terminology clarifications.
• Combined pituitary tumor sections.
• Incidentaloma size threshold aligned with cited ACR white paper.
• Added allowance for absence seizure, other clarifications aligned with operational intent.
• New guideline content for magnetoencephalography and magnetic source imaging.
• Specification of objective findings for dizziness or vertigo aligned with ACR AUC.
• Clarified current hearing loss/tinnitus allowances to align with ACR AUC.
• Specification of prior imaging to allow MRI evaluation for headache.

Imaging of the Extremities

• Removal of non-joint modality for joint indication for septic arthritis.
• Clarification/expansion to allow imaging confirmation for myositis.
• Addition of high-risk site (medial malleolus) for fracture.
• Removal of unsupported content for soft tissue mass.
• Expanded/simplified criteria for labral tear-shoulder.
• Added x-ray per ACR AUC for chronic shoulder pain.
• Removal of operationally vague scenario for ligament and tendon injuries- wrist now addressed under unexplained pain not otherwise specified (NOS).
• Upper extremity pain section combined with triangular fibrocartilage complex tear (no content change).
• Simplification of pain description for labral tear and femoral acetabular impingement- hip.
• X-ray requirement for labral tear and femoral acetabular impingement updated.
• Removal of site-specific exclusions for pain NOS with aligned thresholds for conservative management; updated osteoarthritis grading.

Imaging of the Extremities

• Expanded and simplified allowances for axial spondyloarthropathy aligned with cited diagnostic thresholds.
• Changes to vertebral compression fracture in alignment with ACR AUC recommendations.
• Added specification for new neurologic findings for neck pain and radiculopathy
• Removed intervention candidacy requirement and removed cervical x-ray requirements aligned with ACR AUC.
• Condensed radiculopathy indication and adult/peds criteria.
• Removed intervention candidacy requirement for spinal stenosis and spondylolisthesis
• Title clarification: removed scenario addressed in other sections.

Vascular Imaging

• Cardiac surgery added to procedure-related imaging allows computed tomography (CT) or coronary computed tomography angiography CTA chest.
• Combined post-revascularization imaging and updated alignment with Society for Vascular surgery guidelines.
• Cardiac surgery item moved to procedure related imaging.
• Simplification for acute/subacute stroke/transient ischemic attack by timing for intracranial and extracranial evaluation.
• Specification for same-episode imaging.
• Simplification of content by common presentation for venous thrombosis or compression, intracranial, allowance of CT/MRI in lieu of CTA/magnetic resonance angiography.
• Added CT allowance for acute aortic syndrome (contrast CT may be sufficient for evaluation).
• Alignment of preop indications with duplex ultrasound criteria for physiologic testing for peripheral arterial disease.

Imaging of the Heart

• Coronary CT angiography (CCTA), cardiac MRI, perfusion positron emission tomography (PET), myocardial perfusion imaging (MPI), stress echocardiography.
  • Defined the term “preceding evaluation for coronary artery disease (CAD)” in scenarios where the appropriateness of imaging is based on whether the patient has had a preceding evaluation.
  • Added inconclusive exercise treadmill test as an indication for additional CAD testing.
  • Allow preoperative stress testing for CAD to align with the 2024 American College of Cardiology/American Heart Association joint practice guidelines for perioperative cardiovascular management for noncardiac surgery.
• Resting transthoracic echocardiography (TTE).
  • Recommend surveillance every three to five years in patients with congenital heart defects (for example, small atrial septal defect (ASD), small muscular ventricular septal defect (VSD), small non muscular VSD, and small patent ductus arteriosus).
  • One-time evaluation recommended for first-degree relatives of patients with thoracic aortic aneurysm to detect asymptomatic thoracic aneurysms.

Effective for dates of service on and after November 15, 2025, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Genetic Testing. 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.

Updates by section

Genetic Liquid Biopsy in the Management of Cancer and Cancer Surveillance

• Guideline renamed to encompass ribonucleic acid (RNA) based liquid biopsy tests.
• Liquid circulating tumor deoxyribonucleic acid (DNA) based testing split into general criteria and cancer-site specific criteria.
• General requirements: clarified that genomic testing must have established analytical and clinical validity and be performed in an appropriately certified laboratory.
• General criteria for genetic liquid biopsy testing.
  • Lab developed tests added.
  • Additional criteria added to meet medical necessity.
• Lung carcinoma: replaced American Society of Clinical Oncology with European Society for Medical Oncology Scale for Clinical Actionability of Molecular Targets – comparable, easier to locate, and updated more frequently.
• Biliary tract carcinoma: new criteria added.
• Breast carcinoma:
  • Removed restriction of individual needing to be an adult male or postmenopausal female.
  • National Comprehensive Cancer Network (NCCN) 2A recommendation added as positive criteria.
• Prostate carcinoma: NCCN 2A recommendation added as positive criteria.
• Individuals without malignancy for whom liquid biopsy is used for screening: added test name examples.
• Circulating tumor DNA and minimal residual disease: added test name examples.

Somatic Tumor Testing

• General requirements: clarified that genomic testing must have established analytical and clinical validity and be performed in an appropriately certified laboratory
• Somatic testing of solid tumors:
  • Clarified that immunohistochemistry is out of scope for genetic testing.
  • General criteria:
    • Lab developed tests added as medically necessary.
    • Allow genetic biomarker testing per member's health plan drug-specific policy requirements.
• Tissue-agnostic testing for patients with advanced solid tumors:
  • Removal of restrictive criteria.
  • Added fibroblast growth factor receptor (FGFR) biomarkers as medically necessary tumor testing.
• Bladder cancer (Urothelial carcinoma, including the upper tract):
  • Added NCCN 2A recommendation to positive criteria.
  • Removed restriction to a specific genetic biomarker.
• Breast cancer, localized, early adjuvant setting:
  • Removed breast cancer index (BCI) from early adjuvant setting and a new section was added allowing for the BCI test provided certain criteria are met.
  • Added criteria for the breast cancer index in extended adjuvant setting.
• Breast cancer, metastatic and/or locally advanced breast cancer:
  • Expanded genetic marker testing from four genes to 50 or fewer.
  • Added NCCN 2A recommendation to positive criteria.
• Cholangiocarcinoma (biliary tract cancers):
  • Added another required genetic marker.
  • Added NCCN 2A recommendation to positive criteria.
• Melanoma: removed restriction requiring previous B-rapidly accelerated fibrosarcom (BRAF) V600E testing.
• Non-small cell lung cancer, localized (stage IB-IIIA):
  • Testing for squamous cell histology is now allowed without the requirements of being age ≤50, non-smoker, or light former smoker.
  • Added Food and Drug Administration (FDA) label and NCCN 2A recommended treatments as allowed (expanded beyond two specific treatments).
• Non-small cell lung cancer, advanced (previously metastatic):
  • Testing for squamous cell histology is now allowed without the requirements of being aged 50 or younger, non-smoker, or light former smoker.
  • Added a marker for additional treatment option.
• Ovarian (Epithelial):
  • Removed requirement for an FDA approved test.
  • National Comprehensive Cancer Network 2A recommendation added to positive criteria.
• Pancreatic adenocarcinoma:
  • Neuregulin 1 (NRG1) added as an additional biomarker based on FDA approval.
  • Specify prior tissue-based next-generation sequencing testing.
• Prostate cancer, metastatic:
  • Castrate sensitive metastatic adenocarcinoma of the prostate and castrate resistant metastatic adenocarcinoma of the prostate specified as necessary types of prostate adenocarcinoma.
  • Added NCCN 2A recommendation to positive criteria.
• Sarcoma (including soft tissue sarcoma, bone sarcoma, gastrointestinal stromal tumor, uterine sarcoma): expanded criteria.
• Thyroid cancer:
  • Removed restrictive indeterminate thyroid nodules (ITNs) ultrasound criteria.
  • Allow up to ITNs 4 cm in size.
• Somatic testing of hematologic malignancies.
  • Somatic genomic testing (blood cancer biomarker testing):
    • Added NCCN 2A recommendation to positive criteria.
    • Allow for member's health plan drug-specific policy requirements to positive criteria.
• Blood cancer-specific criteria: clarified that chromosomal testing is out of scope for genetic testing.
• Acute lymphoblastic leukemia and pediatric B-cell precursor lymphoblastic lymphoma: added another cancer type (pediatric BCP-LBL).
• Acute myelogenous leukemia: added FMS-like tyrosine kinase 3 – internal tandem duplication (FLT3-ITD) as medically necessary.
• B-cell lymphomas: new criteria for B-cell lymphomas.
• Chronic lymphocytic leukemia: criteria added for focused next-generation sequencing (NGS) panel for risk stratification.
• Chronic myeloid leukemia: clarified use of focused testing.
• Myelodysplastic syndrome: added genetic marker to examples.

Effective for dates of service on and after November 15, 2025, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Sleep. 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.

Updates by section

Multiple Sleep Latency Testing and Maintenance of Wakefulness Testing

• Clarified idiopathic hypersomnia.

Management of OSA using Auto-titrating PAP and Continuous PAP Devices

• Removed extraneous criteria to determine appropriate continuous PAP level.
• Removal of age restriction from contraindications to auto-titrating PAP.
• Clarification that clinical benefit attestation must come from the treating provider.

Bi-Level PAP Devices

• Clarification that clinical benefit attestation must come from the treating provider.

Management of OSA Using Oral Appliances

• Clarification for patients with periodontal disease or temporomandibular joint dysfunction.

Miscellaneous Devices in the Management of OSA and Restless Legs Syndrome

• Added criteria for restless legs syndrome (RLS) – peroneal nerve stimulation for management of RLS is considered not medically necessary.

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 November 7, 2025

Bariatric Surgery, 7.01.516  PBC | Premera HMO
Medical necessity criteria added:

• Reoperation for inadequate weight loss is considered medically necessary if the original bariatric procedure fails, such as unsuccessful band adjustments, resulting in less than 50% excess weight loss or less than 20% total weight loss.

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

• Docivyx (docetaxel) may be considered medically necessary as a single agent for locally advanced or metastatic breast cancer after chemotherapy failure when criteria are met.
• Treanda (bendamustine) may be considered medically necessary for the treatment of chronic lymphatic leukemia or indolent B-cell non-Hodgkin lymphoma relapsed within six months of bendamustine-rituximab, first-line for follicular lymphoma with rituximab, first-line for untreated mantle cell lymphoma (MCL) in hematopoietic stem cell transplantation ineligible patients when used with bendamustine, Calquence, and rituximab.
• Dactinomycin may be considered medically necessary for various FDA-approved oncologic indications.
• Doxil (doxorubicin hydrochloride liposome) and generic doxorubicin hydrochloride liposome may be considered medically necessary for the treatment of ovarian cancer, acquired immunodeficiency syndrome-related Kaposi’s sarcoma, multiple myeloma (MM) when criteria are met.
• Evomela (melphalan) may be considered medically necessary for use as a high-dose conditioning treatment prior to hematopoietic progenitor (stem) cell transplantation in individuals with MM.
• Floxuridine may be considered medically necessary for the palliative management of gastrointestinal adenocarcinoma metastatic to the liver in individuals who are considered incurable by surgery or other means.
• Grafapex (treosulfan) may be considered medically necessary for the treatment of acute myeloid leukemia or myelodysplastic syndrome when criteria are met.
• Generic eribulin mesylate may be considered medically necessary for the treatment of metastatic breast cancer and unresectable or metastatic liposarcoma when criteria are met.
• Kepivance (palifermin) may be considered medically necessary to decrease the incidence and duration of severe oral mucositis when criteria are met.
• Khapzory (levoleucovorin) may be medically necessary for methotrexate rescue in osteosarcoma, folic acid antagonist overdose, impaired methotrexate elimination, or with fluorouracil for metastatic colorectal cancer when criteria are met.
• Portrazza (necitumumab) may be considered medically necessary for the treatment of metastatic squamous non-small cell lung cancer.
• Trisenox (arsenic trioxide) may be medically necessary for low-risk acute promyelocytic leukemia (APL) with t(15;17) or PML/RARα, in combination with tretinoin, or for relapsed/refractory APL after retinoid and anthracycline therapy when criteria are met.

Percutaneous Coronary Intervention, Angioplasty, Non-Emergent in Adults, 2.02.508  PBC | Premera HMO
New policy:

• Percutaneous coronary intervention is considered medically necessary for select conditions when criteria are met.

Site of Service Ambulatory Service Center (ASC) Select Surgical Procedures, 11.01.525  PBC | Premera HMO
New policy:

• Site of Service for ASC for Select Surgical Procedures will be considered medically necessary when criteria are met.
• This policy will apply to the following policies:
  • Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions, 7.01.607  PBC | Premera HMO
  • Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.48  PBC | Premera HMO
  • Breast Reduction (Mammaplasty), 7.01.503  PBC | Premera HMO
  • Knee Arthroscopy in Adults, 7.01.549  PBC | Premera HMO
  • Meniscal Allografts and Other Meniscal Implants, 7.01.15  PBC | Premera HMO
  • Reconstructive Breast Surgery/Management of Breast Implants, 7.01.533  PBC | Premera HMO
  • Rhinoplasty and Other Nasal Procedures, 7.01.558  PBC | Premera HMO
  • Sinus Surgery, 7.01.559  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, 7.01.554  PBC | Premera HMO

Medical necessity criteria added:

• Site of Service Ambulatory Service Center (ASC) Select Surgical Procedures, 11.01.525 criteria added.
• These services, which were previously reviewed for site of service in the inpatient setting, will now be reviewed for site of service when requested outside of the ASC setting.
• An elective surgical procedure performed in a hospital outpatient department may be considered medically necessary if there is no access to an ASC when criteria are met.

Total Ankle Arthroplasty in Adults, 7.01.599  PBC | Premera HMO
New policy:

• Total ankle arthroplasty may be considered medically necessary when criteria are met.

Revised medical policies
Effective November 1, 2025

Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions, 7.01.607  PBC | Premera HMO
Policy renumbered:

• This policy replaces autografts and allografts in the treatment of focal articular cartilage lesions, 7.01.78, which is now deleted.

Medical necessity criteria updated:

• Clarification of size (when defect size is greater than 2.5 cm²) added to fresh osteochondral allografting criteria.

New pharmacy policies
Effective November 1, 2025

Denosumab Biosimilars, 5.01.658  PBC | Premera HMO
New policy:

• Prolia (denosumab) moved from pharmacologic treatment of osteoporosis, 5.01.596 to denosumab biosimilars, 5.01.658.
• Xgeva (denosumab) moved from miscellaneous oncology drugs, 5.01.540 to denosumab biosimilars, 5.01.658.
• Criteria added for Bildyos (denosumab-nxxp), Bilprevda (denosumab-nxxp), Bomyntra (denosumab-bnht), Conexxence (denosumab-bnht), Jubbonti (denosumab-bbdz), Osenvelt (denosumab-bmwo), Ospomyv (denosumab-dssb), Stoboclo (denosumab-bmwo), Wyost (denosumab-bbdz), and Xbryk (denosumab-dssb).

Revised pharmacy policies
Effective November 1, 2025

Amyloid Antibodies for the Treatment of Alzheimer’s Disease, 5.01.626  PBC | Premera HMO
Medical necessity criteria added:

• Leqembi Iqlik (lecanemab-irmb) for the treatment of adults with Alzheimer’s disease when criteria are met.

Bruton’s Kinase Inhibitors, 5.01.590  PBC | Premera HMO
Medical necessity criteria added:

• Wayrilz (rilzabrutinib) for the treatment of persistent or chronic immune thrombocytopenia in individuals who have had an insufficient response to a previous treatment when criteria are met.

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

• Empaveli (pegcetacoplan) for the treatment of adult and pediatric individuals aged 12 years and older with C3 glomerulopathy or primary immune-complex membranoproliferative glomerulonephritis to reduce proteinuria when criteria are met.

CGRP Inhibitors for Migraine Prophylaxis, 5.01.584  PBC | Premera HMO
Medical necessity criteria updated:

• Ajovy (fremanezumab-vfrm) the preventive treatment of episodic migraine in children aged six to 17 years when criteria are met.

Chronic Hepatitis B Antiviral Therapy, 5.01.636  PBC | Premera HMO
Medical necessity criteria updated:

• Pegasys (peginterferon alfa-2a) criteria to include treatment of myelofibrosis when criteria are met.

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

• Gamifant (emapalumab-lzsg) for the treatment of certain individuals with hemophagocytic lymphohistiocytosis or macrophage activation syndrome when criteria are met.

Medical necessity criteria added:

• Livmarli (maralixibat) criteria updated to clarify dose limitations.
• Ctexli (chenodiol) and Cholbam (cholic acid) criteria updated to clarify that the treatments will not be used concomitantly.

Gonadotropin Releasing Hormone (GnRH) Analogs, 5.01.625  PBC | Premera HMO
Drug added:

• Vabrinity (leuprolide acetate) for the treatment of prostate cancer when criteria are met.

HER2 Inhibitors, 5.01.514  PBC | Premera HMO
Drug/medical necessity criteria added (p. 2):

• Hernexeos added for the treatment of adults with unresectable or metastatic non-squamous non–small cell lung cancer harboring human epidermal growth factor receptor 2 (ERBB2) tyrosine kinase domain activating mutations, and who have received prior systemic therapy.

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

• Fasenra (benralizumab) and Nucala (mepolizumab) EGPA criteria to clarify:
  • Presence of anti-neutrophil cytoplasmic antibody meets the requirement.

Medical necessity criteria removed:

• Requirement to have signs or symptoms of chronic bronchitis removed from Nucala (mepolizumab) chronic obstructive pulmonary disease criteria.

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

• Keytruda Qlex (pembrolizumab and berahyaluronidase alfa-pmph) for treatment of unresectable, metastatic, or high-risk cancers across multiple tumor types when criteria are met.

Insulin Therapy, 5.01.648  PBC | Premera HMO
Medical necessity criteria added:

• Kirsty (insulin aspart-xjhz) added as a non-preferred rapid-acting insulin across all sections.

Management of Opioid Therapy, 5.01.529  PBC | Premera HMO
Medical necessity criteria added and updated:

• Duragesic (brand product), Fentora, Kadian (brand product), Zohydro ER (brand product) were removed from the policy (obsolete).
• Clarified durations of approval:
  • Long-acting opioid drugs may be approved up to 12 months.
  • Quantity limit exception for long-acting opioid drugs may be approved on a case-by-case basis for a maximum of three months.

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

• Avsola (infliximab-axxq) and Renflexis (infliximab-abda) for the treatment of uveitis when criteria are met.

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

• Mezofy (aripiprazole oral film) added to Antipsychotics, Second Generation.
• Added Clindesse (clindamycin), Nuvessa (metronidazole), and Xaciato (clindamycin) for the treatment of bacterial vaginosis when criteria are met.
• Added Nocdurna (desmopressin sublingual tablets) for the treatment of nocturia due to nocturnal polyuria when criteria are met.
• Eurax (crotamiton) and Pruradik (crotamiton) for the treatment of scabies when criteria are met.
• Lorpressor (metoprolol oral solution) for individuals with an inadequate response or intolerance to two generic beta blockers.
• Relistor (methylnaltrexone) tablets and Symproic (naldemedine) for the treatment of opioid-induced constipation in individuals with chronic, non-cancer pain when criteria are met.
• Tryptyr (acoltremon ophthalmic solution) for the treatment of signs and symptoms of dry eye disease when criteria are met.
• Arixtra (fondaparinux) when the individual has tried and had an inadequate response or intolerance to generic fondaparinux.
• Kerendia (finerenone) for the treatment of heart failure when criteria are met.
• Hemiclor (chlorthalidone tablet) when the individual has tried generic chlorthalidone tablet and had an inadequate response or intolerance to generic chlorthalidone tablet.
• Inzirqo (hydrochlorothiazide oral suspension) when the individual has had an inadequate response or intolerance to two generic thiazide diuretics.
• Generic diazoxide and Proglycem (diazoxide) for the treatment of hypoglycemia due to hyperinsulinism when criteria are met.
• Harliku (nitisinone) for the reduction of urine homogentisic acid in adult individuals with alkaptonuria when criteria are met.
• Generic tolvaptan for the treatment of progressing autosomal dominant polycystic kidney disease.
• Vizz (aceclidine) for the treatment of presbyopia when criteria are met.
• Rayaldee (calcifediol) for the treatment of secondary hyperparathyroidism when criteria are met.
• Journavx (suzetrigine) added to the quantity limits.
  • Twenty-nine tablets per 14 days.
  • One treatment course every 42 days.
• Veozah (fezolinetant) added to the quantity limits.
  • Thirty tablets per 30 days.

Medical necessity criteria removed:

• Cayston (aztreonam) moved from medical necessity criteria for pharmacy edits, 5.01.605 to pharmacologic treatment of cystic fibrosis5.01.539.
• Gabapentin products, generic gabapentin extended release (Gralise), Gabarone (gabapentin), and Horizant (gabapentin extended release) from medical necessity criteria for pharmacy edits, 5.01.605 to pharmacologic treatment of neuropathy, fibromyalgia, and seizure disorders, 5.01.521.
• Giazo (balsalazide) removed from ulcerative colitis agents as the product has been discontinued.
• Veozah (fezolinetant) criteria removed.

Medical necessity criteria updated:

• Generic nitisinone, Nityr (nitisinone), and Orfadin (nitisinone) updated to include coverage for the reduction of urine homogentisic acid in adult individuals with alkaptonuria when criteria are met.

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

• Atzumi (dihydroergotamine) nasal spray and Trudhesa (dihydroergotamine) nasal spray to require the individual is aged 18 years or older, has tried one non-oral triptan medication, has tried generic dihydroergotamine nasal spray, and to limit the quantity dispensed to 12 doses per 30 days.
• Migranal (dihydroergotamine) nasal spray to require the individual is aged 18 years or older, has tried one non-oral triptan medication, and has tried generic dihydroergotamine nasal spray.

Medical necessity criteria added:

• Brekiya (dihydroergotamine) injection for the acute treatment of migraine or cluster headaches when criteria are met.

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

• Modeyso (dordaviprone) for the treatment of diffuse midline glioma when criteria are met.
• Inlexzo (gemcitabine intravesical system) for the treatment of Bacillus Calmette-Guérin (BCG) unresponsive, non-muscle invasive bladder cancer (NMIBC) when criteria are met.

Medical necessity criteria removed:

• Xgeva (denosumab) moved from policy 5.01.540 miscellaneous oncology drugs to 5.01.658 denosumab products.

Pharmacologic Prevention and Treatment of HIV/AIDS, 5.01.588  PBC | Premera HMO
Medical necessity criteria added:

• Yeztugo (lenacapavir) for pre-exposure prophylaxis to reduce the risk of human immunodeficiency virus -1 infection when criteria are met.

Pharmacologic Treatment of Chronic Non-Infectious Liver Diseases, 5.01.615  PBC | Premera HMO
Medical necessity criteria updated:

• Updated Rezdiffra (resmetirom) criteria:
  • Clarify that Rezdiffra can be prescribed by or in consultation with an endocrinologist as well.
  • Remove the statin requirements and clarify that the individual is being treated for any concomitant conditions.

Pharmacologic Treatment of Epidermolysis Bullosa, 5.01.635  PBC | Premera HMO
Medical necessity criteria updated:

• Vyjuvek (beremagene geperpavec-svdt) criteria updated removing the age requirement and updating the maximum weekly dose based on age.

Pharmacologic Treatment of Interstitial Lung Disease, 5.01.555  PBC | Premera HMO
Drug added:

• Avtozma (tocilizumab-anoh) IV/SC for the treatment of interstitial lung disease associated with systemic sclerosis when criteria are met.
• Yutrepia (treprostinil) for the treatment of pulmonary hypertension associated interstitial lung disease when criteria are met.

Medical necessity criteria updated:

• Updated Actemra (tocilizumab) and Tyenne (tocilizumab-aazg) criteria:
  • Removed criteria requiring carbon monoxide diffusing capacity of at least 45% of the predicted value.
  • Added criteria specifying that the individual has elevated acute phase reactants defined as one of the following: C-reactive protein at least 6 mg/mL, erythrocyte sedimentation rate at least 28 mm/h, or platelet count at least 330 x 109/L.

Pharmacologic Treatment of Neuropathy, Fibromyalgia, and Seizure Disorders, 5.01.521  PBC | Premera HMO
Medical necessity criteria moved:

• Gabapentin products (generic gabapentin extended release), Gralise (gabapentin extended release), Gabarone (gabapentin), and Horizant (gabapentin extended release) from medical necessity criteria for pharmacy edits, 5.01.605 to pharmacologic treatment of neuropathy, fibromyalgia, and seizure disorders, 5.01.521.

Medical necessity criteria updated:

• Generic gabapentin extended release, Gralise, Gabarone, and Horizant for the management of neuropathic pain updated to require the individual is 18 years of age or older, has tried gabapentin and pregabalin or pregabalin extended release, and a tricyclic antidepressant or serotonin-norepinephrine reuptake inhibitor
• Gabarone to include criteria for the treatment of a seizure disorder when criteria are met.
• Horizant for the treatment of restless leg syndrome to require the individual is 18 years of age or older and has tried gabapentin and pregabalin or pregabalin extended release.
• Savella (milnacipran) coverage criteria for the treatment of fibromyalgia to include generic pregabalin and pregabalin extended release as an alternative to use of generic gabapentin.

Medical necessity criteria added:

• Tonmya (cyclobenzaprine sublingual tablet) for the treatment of fibromyalgia when criteria are met.

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

• Javygtor, Kuvan, and generic sapropterin will not be used in combination with Palynziq (pegvaliase-pqpz) or Sephience (sepiapterin).
• Palynziq will not be used in combination with generic sapropterin, Javygtor (sapropterin), Kuvan (sapropterin), or Sephience (sepiapterin).

Medical necessity criteria added:

• Sephience (sepiapterin) for the treatment of hyperphenylalaninemia in adult and pediatric individuals one month of age and older with sepiapterin-responsive phenylketonuria.

Pharmacotherapy of Arthropathies, 5.01.550  PBC | Premera HMO
Drug added:

• Avtozma (tocilizumab-anoh) intravenous/ subcutaneous (IV/SC) for the treatment of polyarticular juvenile idiopathic arthritis when criteria are met.

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

• Avsola (infliximab-axxq), Inflectra (infliximab-dyyb), infliximab (Janssen – unbranded), Remicade (infliximab), and Renflexis (infliximab-abda) to include coverage criteria for the treatment of uveitis when criteria are met.
• Avtozma (tocilizumab-anoh) IV/SC may be considered medically necessary for the treatment of giant cell arteritis when criteria are met.

Pharmacotherapy of Thrombocytopenia, 5.01.566  PBC | Premera HMO
Drug/medical necessity criteria added:

• Doptelet Sprinkle (avatrombopag) oral granules for the treatment of thrombocytopenia in pediatric individuals aged one year to less than six years with persistent or chronic immune thrombocytopenia.

Medical necessity criteria updated:

• Doptelet tablet age threshold updated from 18 years or older to six years and older for the treatment of persistent or chronic immune thrombocytopenia when criteria are met.

Use of Granulocyte Colony-Stimulating Factors (G-CSF), 5.01.551 PBC | Premera HMO
Drugs added (p. 6 – 7):

• Releuko (filgrastim-ayow) as second-line therapy for adult and pediatric individuals undergoing autologous peripheral blood progenitor cell collection.
• Fylnetra (pegfilgrastim-pbbk) and Releuko (filgrastim-ayow) for use as first-line therapy in adult and pediatric individuals acutely exposed to myelosuppressive doses of radiation.

No updates this month.

Effective November 1, 2026

Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions, 7.01.78
Policy deleted:

• This policy is replaced with autografts and allografts in the treatment of focal articular cartilage lesions, 7.01.607.

Added codes
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, 1.01.518  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 November 15, 2025

Carelon Management Radiology Oncology
Reviewed by Carelon Medical Benefits Management for medical necessity and prior authorization.

95965, 95966

Carelon Management Sleep Disorder Management
Reviewed by Carelon Medical Benefits Management for medical necessity and prior authorization.

A4544, E0743

Effective November 7, 2025

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

J9120, J9172, Q2050, J9246, J2425, J9200, J9295, J9017, J9033

Percutaneous Coronary Intervention, Angioplasty, Non-Urgent in Adults, 2.02.508  PBC | Premera HMO
Requires review for medical necessity.

C9600, C9601, C9602, C9603

Requires review for medical necessity and prior authorization.

92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937,92938, 92941, 92943, 92944, 92980, 92982

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

19318, 27412, 27415, 27416, 28446, 29866, 29867, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29888, 29889, 30400, 30410, 30420, 30430, 30435, 30450, 31233, 31235, 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31295, 31296, 31297, 31298, 42145, 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, J7330, S2112

Total Ankle Arthroplasty in Adults, 7.01.599  PBC | Premera HMO
Requires review for medical necessity and prior authorization.

27700, 27702, 27703

Effective November 1, 2025

Carelon Management Sleep Disorder Management
Reviewed by Carelon Medical Benefits Management for medical necessity and prior authorization.

0964T, 0965T, 0966T

Denosumab Products, 5.01.658  PBC | Premera HMO
Requires review for medical necessity and prior authorization.

Q5136, Q5157, Q5158, Q5159

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

0556U, 0580U

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

Q5104, Q5121

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

J0614

Pharmacologic Treatment of Osteoporosis, 5.01.596  PBC | Premera HMO
Requires review for medical necessity and prior authorization.

J0897

Site of Service: Infusion Drugs and Biologic Agents, 11.01.523  PBC | Premera HMO
Requires review for medical necessity, in addition to current review for site of service and prior authorization.

Q5156

Removed codes
Effective January 2, 2026

Non-covered Services and Procedures, 10.01.517  PBC | Premera HMO
No longer requires review.

G0023, G0024

Effective November 15, 2025

Non-covered Experimental/Investigational Services, 10.01.533  PBC | Premera HMO
No longer considered investigational. Reviewed by Carelon for medical necessity and prior authorization.

A4544, E0743

Effective November 1, 2025

Amyotrophic Lateral Sclerosis (ALS) Medications, 5.01.578  PBC | Premera HMO
No longer requires review.

J1301

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, 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 HMOThyroid 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/nutritional panel testing, 2.04.136 deleted and replaced with RTM policy intracellular micronutrient analysis, 15.01.041.

No updates this month.

Effective January 2, 2026

High-Resolution Anoscopy, 2.01.539  PBC | Premera HMO
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.

Effective November 7, 2025

Eye-Anterior Segment Optical Coherence Tomography, 9.03.509  PBC | Premera HMO
Requires review for medical necessity and prior authorization.

92133, 92134, 92137

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 (FEP) will require review for medical necessity 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