Medical Policy and Coding Updates

Effective January 2, 2026

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

• Open, laparoscopic, or 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 2 and 3

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 WA Mandate, effective January 1, 2026:
  • Coverage for minors under 18 requires medical clearance within the past 6 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 3–4 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 (e.g., 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 HOPD when technique consistency is needed for comparison
  • Imaging required for pre-procedural planning when the procedure is scheduled at the same hospital
  • Clinically significant delays in care would be expected if imaging were redirected outside the HOPD

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

Effective December 4, 2025

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

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

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

• NPWT devices are considered medically necessary when criteria are met

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; 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 eval)
• 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 PET, Myocardial Perfusion Imaging (MPI), Stress Echocardiography
  • Defined the term “preceding evaluation for CAD [coronary artery disease]” 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)
  • Surveillance recommended every 3 to 5 years in patients with congenital heart defects (i.e., 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: Test name examples added
• Circulating tumor DNA and Minimal Residual Disease: Test name examples added

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 FGFR biomarkers as medically necessary tumor testing
• Bladder Cancer (Urothelial Carcinoma, including the Upper Tract):
  • NCCN 2A recommendation added 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 4 genes to 50 or fewer
  • NCCN 2A recommendation added to positive criteria
• Cholangiocarcinoma (Biliary Tract Cancers):
  • Added another required genetic marker
  • NCCN 2A recommendation added to positive criteria
• Melanoma: Removed restriction requiring previous 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
  • NCCN 2A recommendation added to positive criteria
• Pancreatic Adenocarcinoma:
  • 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
  • NCCN 2A recommendation added 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):
    • NCCN 2A recommendation added 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 FLT3-ITD as medically necessary
• B-cell Lymphomas: New criteria for B-cell lymphomas
• Chronic Lymphocytic Leukemia: Criteria added for focused 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

• Clarification of 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 6 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, 7.01.78  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

Effective October 3, 2025

Alpha1-Proteinase Inhibitors, 5.01.624  PBC | Premera HMO
C3 and C5 Complement Inhibitors, 5.01.571  PBC | Premera HMO
CGRP Inhibitors for Migraine Prophylaxis, 5.01.584  PBC | Premera HMO
Hereditary Angioedema, 5.01.587  PBC | Premera HMO
Immune Globulin Therapy, 8.01.503  PBC | Premera HMO
Medical Pharmacologic Treatments of Multiple Sclerosis, 5.01.644  PBC | Premera HMO
Nulojix (belatacept) for Adults, 5.01.536  PBC | Premera HMO
Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570  PBC | Premera HMO
Pharmacologic Treatment of Sickle Cell Disease, 5.01.640  PBC | Premera HMO
Pharmacotherapy of Arthropathies, 5.01.550  PBC | Premera HMO
Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  PBC | Premera HMO
Rituximab: Non-oncologic and Miscellaneous Uses, 5.01.556  PBC | Premera HMO
Xolair (omalizumab), 5.01.513  PBC | Premera HMO
Medical necessity criteria updated

• Clarified that site of service criteria can apply to injection drugs

Balloon Spacers for Treatment of Irreparable Rotator Cuffs of the Shoulder, 7.01.180  PBC | Premera HMO
New policy

• Subacromial balloon spacer implantation is considered investigational as a treatment for massive, irreparable, full-thickness rotator cuff tears

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

• Clarified that site of service criteria can apply to injection drugs
• Site of service review added for Tepezza (teprotumumab-trbw)

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

• Clarified that site of service criteria can apply to injection drugs
• Site of service review added to Fasenra (benralizumab) and Nucala (mepolizumab)

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

• Clarified that site of service criteria can apply to injection drugs
• Site of service review added to the following drugs: Imfinzi (durvalumab), Jemperli (dostarlimab-gxly), Opdivo Qvantig (nivolumab-hyaluronidase-nvhy), Tecentriq (atezolizumab), and Tecentriq Hybreza (atezolizumab-hyaluronidase-tqjs)

Implantable Cardioverter-Defibrillator (ICD), 7.01.44  PBC | Premera HMO
New policy

• Automatic implantable cardioverter defibrillators (ICD) for the treatment of heart failure in pediatric and adult individuals may be considered medically necessary when criteria are met
• Subcutaneous ICDs for individuals with an indication for ICD implantation may be considered medically necessary when criteria are met

Miscellaneous Pharmacologic Treatments of Psoriasis, 5.01.652  PBC | Premera HMO
New policy

• The following medically necessary drugs (when criteria are met) were moved from Pharmacologic Treatment of Psoriasis, 5.01.629 to Miscellaneous Pharmacologic Treatments of Psoriasis, 5.01.652: Vtama (tapinarof), Zoryve (roflumilast) cream, Duobrii (halobetasol and tazarotene), Enstilar (betamethasone and calcipotriene), Taclonex (betamethasone and calcipotriene), Wynzora (betamethasone and calcipotriene), brand calcipotriene foam, Dovonex (calcipotriene), Sorilux (calcipotriene), Vectical (calcitriol), Soriatane (acitretin), and Spevigo (spesolimab-sbzo)

Medical necessity criteria updated

• Clarified that site of service criteria can apply to injection drugs

Pharmacologic Treatment of Gout, 5.01.616 PBC | Premera HMO
Medical necessity criteria updated

• Clarified that site of service criteria can apply to injection drugs
• Site of service review added to Ilaris (canakinumab)

Pharmacologic Treatment of Osteoporosis, 5.01.596 PBC | Premera HMO
Medical necessity criteria updated

• Clarified that site of service criteria can apply to injection drugs
• Site of service review added to the following drugs: Evenity (romosozumab-aqqg)

Medical necessity criteria added

• Generic calcitonin salmon injection and Miacalcin (calcitonin salmon) injection may be considered medically necessary for the treatment of postmenopausal osteoporosis, Paget’s disease of bone, and hypercalcemia when criteria are met

Pharmacologic Treatment of Parkinson's Disease, 5.01.651 PBC | Premera HMO
Medical necessity criteria added

• Clarified that Apokyn coverage criteria will apply to the medical benefit

Pharmacologic Treatment of Psoriasis, 5.01.629 PBC | Premera HMO
Pharmacologic Treatment of Psoriatic Arthritis, 5.01.645 PBC | Premera HMO
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563 PBC | Premera HMO
Medical necessity criteria updated

• Clarified that site of service criteria can apply to injection drugs
• Section 1: Stelara (ustekinumab) criteria updated to require trial with Steqeyma (ustekinumab-aauz) and Yesintek (ustekinumab-kfce) for individuals not previously treated
• Sections 2 and 3: Stelara (ustekinumab) criteria updated to require trial with Steqeyma (ustekinumab-aauz) and Yesintek (ustekinumab-kfce)

New formatting

• Section 1 includes Open/Preferred/Select formulary plans and plans with no pharmacy benefit coverage
• Section 2 includes Essentials formulary plans
• Section 3 includes Metallic formulary plans

Pharmacologic Treatment of Psoriasis, 5.01.629 PBC | Premera HMO
New formatting

• Different criteria added for Metallic formulary and Essentials formulary plans for the following drugs: Enbrel (etanercept), adalimumab products, infliximab products, Taltz (ixekizumab), ustekinumab products, Skyrizi (risankizumab-rzaa), Tremfya (guselkumab), Otezla (apremilast), Sotyktu (deucravacitinib), Bimzelx (bimekizumab-bkzx), Siliq (brodalumab), Cosentyx (secukinumab), Cimzia (certolizumab pegol), and Ilumya (tildrakizumab-asmn)

Medical necessity criteria removed

• The following medically necessary drugs (when criteria are met) were moved from Pharmacologic Treatment of Psoriasis, 5.01.629 to Miscellaneous Pharmacologic Treatments of Psoriasis, 5.01.652: Vtama (tapinarof), Zoryve (roflumilast) cream, Duobrii (halobetasol and tazarotene), Enstilar (betamethasone and calcipotriene), Taclonex (betamethasone and calcipotriene), Wynzora (betamethasone and calcipotriene), brand calcipotriene foam, Dovonex (calcipotriene), Sorilux (calcipotriene), Vectical (calcitriol), Soriatane (acitretin), and Spevigo (spesolimab-sbzo)

Pharmacologic Treatment of Psoriatic Arthritis, 5.01.645  PBC | Premera HMO
New formatting

• Different coverage criteria for Metallic formulary and Essentials formulary plans for the following drugs: Enbrel (etanercept), adalimumab products, infliximab products, Taltz (ixekizumab), ustekinumab products, Skyrizi (risankizumab-rzaa), Tremfya (guselkumab), Otezla (apremilast), Bimzelx (bimekizumab-bkzx), Cosentyx (secukinumab), Cimzia (certolizumab pegol), Rinvoq/Rinvoq LQ (upadacitinib), Xeljanz/Xeljanz XR (tofacitinib extended-release), Simponi (golimumab), Simponi Aria (golimumab), Rinvoq LQ (upadacitinib), and Orencia (abatacept)

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

• Site of service review added for Zymfentra (infliximab-dyyb)

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

• Clarified that site of service criteria can apply to injection drugs
• Site of service review added to the following drugs: Saphnelo (aninfrolumab-fnia), Vyvgart (efgartigimod alfa-fcab), and Vyvgart Hytrulo (efgartigimod alfa-hyaluronidase-qvfc)

Prostatic Urethral Lift, 7.01.598  PBC | Premera HMO
New policy

• Prostatic urethral lift for the treatment of moderate-to-severe lower urinary tract obstruction due to benign prostatic hyperplasia may be considered medically necessary when criteria are met

Site of Service: Drugs and Biologic Agents, 11.01.523 PBC | Premera HMO
Title changed

• Updated policy title from “Site of Service: Infusion Drugs and Biologic Agents” to “Site of Service: Drugs and Biologic Agents”

Medical necessity criteria updated

• Clarified that site of service criteria can apply to injection drugs

Medical necessity criteria added

• Site of service review added to the following drugs: Evenity (romosozumab-aqqg), Fasenra (benralizumab), Ilaris (canakinumab), Imfinzi (durvalumab), Jemperli (dostarlimab-gxly), Nucala (mepolizumab), Ocrevus Zunovo (ocrelizumab-hyaluronidase-ocsq), Opdivo Qvantig (nivolumab-hyaluronidase-nvhy), Saphnelo (aninfrolumab-fnia), Tecentriq (atezolizumab), Tecentriq Hybreza (atezolizumab-hyaluronidase-tqjs), Tepezza (teprotumumab-trbw), Tezspire (tezepelumab-ekko), Vyepti (eptinezumab-jjmr), Vyvgart (efgartigimod alfa-fcab), Vyvgart Hytrulo (efgartigimod alfa-hyaluronidase-qvfc), Xolair (omalizumab), and Zymfentra (infliximab-dyyb)

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

• Clarified that site of service criteria can apply to injection drugs
• Site of service review added for Tezspire (tezepelumab-ekko)

Wearable Cardioverter-Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement, 2.02.506  PBC | Premera HMO
Medical necessity criteria removed

• ICD content removed from Wearable Cardioverter-Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement, 2.02.506 and added to Implantable Cardioverter-Defibrillator (ICD), 7.01.44

New medical policies
Effective October 1, 2025

Urinary Test for Renal Allograft Dysfunction, 7.03.15  PBC | Premera HMO
New policy

• The measurement of urinary CXCL10 chemokines to monitor for dysfunction or determine the need for graft biopsy after renal transplant is considered investigational

Revised medical policies
Effective October 1, 2025

Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers, 1.01.18 PBC | Premera HMO
Title Changed

• Policy title changed from Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers to Compression Pumps for Treatment of Lymphedema and Venous Ulcers

Medical necessity criteria added

• Nonprogrammable and programable pneumatic compression pumps for lymphedema of the chest and trunk may be considered medically necessary when criteria are met
• Programmable non-pneumatic compression pumps (e.g. Koya Dayspring) may be considered medically necessary when criteria are met

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

• Clarified contraindications:
  • Brain tumor – TMS allowed only if neurologist/neurosurgeon confirms safety
  • Implanted stimulators – exception added if MRI-safe per physician documentation
• Added clarifications and updates:
  • Defined short TMS course (brief/mini/booster)
  • Notes on extending full courses and six-treatment tapers
  • Pulse/frequency changes as medically necessary for motor threshold re-checks
  • Criteria for extensions based on documented depression severity; no absolute extension limit
  • Extended taper ≥six treatments over >three weeks
  • Repeat courses must be for same disorder; prior medical necessity criteria apply if initial course was not under Company plan

Tumor Treating Fields Therapy, 1.01.29  PBC | Premera HMO
Investigational criteria added

• Non-small cell lung cancer added to list of conditions for which the therapy is considered investigational

Revised pharmacy policies
Effective October 1, 2025

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

• Nucala (mepolizumab) nasal polyps criteria updated
  • Removed the requirement to have at least one surgery to treat nasal polyps within the last ten years
  • Require prior use of systemic corticosteroids to treat nasal polyps in the last two years or previous surgical removal of the bilateral nasal polyps

Growth Hormone Therapy, 5.01.500  PBC | Premera HMO
Medical necessity criteria updated

• Skytrofa (lonapegsomatropin-tcgd) criteria updated to include treatment of growth hormone deficiency in adult individuals when criteria are met

Hereditary Angioedemas, 5.01.587  PBC | Premera HMO
Medical necessity criteria added

• Andembry (garadacimab-gxii) and Dawnzera (donidalorsen) may be considered medically necessary for the treatment of long-term prophylaxis of acute angioedema attacks when criteria are met
• Ekterly (sebetralstat) may be considered medically necessary for the treatment of acute attacks of angioedema when criteria are met
  • Ekterly added as a qualifying acute treatment drug within criteria for Cinryze, Haegarda, Orladeyo, and Takhzyro

Medical Necessity Criteria for Custom Open and Preferred Formularies, 5.01.647  PBC | Premera HMO
Drug removed

• Idacio (adalimumab-aacf) removed from policy as it has been withdrawn from the market

Pharmacologic Treatment of Hemophilia, 5.01.581  PBC | Premera HMO
Medical necessity criteria updated

• Alhemo (concizumab-mtci) criteria updated to include coverage for patients with or without factor VIII or factor IX inhibitors

Pharmacologic Treatment of Psoriasis, 5.01.629  PBC | Premera HMO
Drug removed

• Idacio (adalimumab-aacf) removed from policy as it has been withdrawn from the market

Medical necessity criteria added

• Starjemza (ustekinumab-hmny) may be considered medically necessary for the treatment of moderate to severe plaque psoriasis when criteria are met

Pharmacologic Treatment of Psoriatic Arthritis, 5.01.645  PBC | Premera HMO
Drug removed

• Idacio (adalimumab-aacf) removed from policy as it has been withdrawn from the market

Medical necessity criteria added

• Starjemza (ustekinumab-hmny) may be considered medically necessary for the treatment of moderate to severe plaque psoriasis when criteria are met

Pharmacotherapy of Arthropathies, 5.01.550  PBC | Premera HMO
Drug removed

• Idacio (adalimumab-aacf) removed from policy as it has been withdrawn from the market

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  PBC | Premera HMO
Drug removed

• Idacio (adalimumab-aacf) removed from policy as it has been withdrawn from the market

Medical necessity criteria added

• Starjemza (ustekinumab-hmny) may be considered medically necessary for the treatment of moderate to severe plaque psoriasis when criteria are met

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  PBC | Premera HMO
Drug removed

• Idacio (adalimumab-aacf) removed from policy as it has been withdrawn from the market

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

• Generic eltrombopag may be considered medically necessary for the treatment of Hepatitis C-associated thrombocytopenia and other select conditions when criteria are met

Medical necessity criteria updated

• Alvaiz (eltrombopag choline) and Promacta (eltrombopag olamine) criteria updated to require trial with generic eltrombopag

No updates this month.

No updates this month.

Added codes
Effective January 2, 2026

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

J1932

Effective December 4, 2025

Negative Pressure Wound Therapy (NPWT) Devices, 1.01.508  PBC | Premera HMO
Now 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 Radiology Benefit Management Program
Now reviewed by Carelon Specialty Health for medical necessity and prior authorization.

95965, 95966

Carelon Sleep Program
Now reviewed by Carelon Specialty Health for medical necessity and prior authorization.

A4544, E0743

Effective November 7, 2025

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

92133, 92134, 92137

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

C9600, C9601, C9602, C9603

Now 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
Now 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
Now requires review for medical necessity and prior authorization.

27700, 27702, 27703

Effective October 3, 2025

Balloon Spacers for Treatment of Irreparable Rotator Cuffs of the Shoulder, 7.01.180  PBC | Premera HMO
Now considered investigational.

C9781

Carelon Management Sleep Disorder Management
Now reviewed by Carelon Specialty Health for medical necessity and prior authorization.

0964T, 0965T, 0966T

Implantable Cardioverter Defibrillator (ICD), 7.01.44  PBC | Premera HMO
Now requires review for medical necessity.

C1721, C1722, C1824, C1882, C1895, C1896, C1899

Now requires review for medical necessity and prior authorization.

33216, 33217, 33230, 33231, 33240, 33249, 33270, 33271, 93260, 93282-93284, 93287, 93289, 0572T

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

J0630

Pharmacologic Treatment of Parkinson's Disease, 5.01.651  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J0364

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J1748

Prostatic Urethral Lift, 7.01.598  PBC | Premera HMO
Now requires review for medical necessity.

C9739, C9740

Now requires review for medical necessity and prior authorization.

52441, 52442

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

J3111, J0517, J0638, J9173, J9272, J2182, J2351, J9622, J0491, J9022, J9024, J3241, J2356, J3032, J9332, J9334, J2357, J1748

Effective October 1, 2025

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

Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4391, Q4392, Q4393, Q4394, Q4395, Q4396, Q4397

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

C9306

Now requires review for medical necessity and prior authorization.

J9011

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

A2036, A2037, A2038, A2039

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

0575U, 0576U, 0578U, 0582U, 0583U, 0585U, 0586U, 0592U, 0597U

Durable Medical Equipment, 1.01.529  PBC | Premera HMO
Now non-covered.

E0150

Evaluation of Biomarkers for Alzheimer Disease, 2.04.521  PBC | Premera HMO
Now considered investigational.

0596U

Gender Transition/Affirmation Surgery and Related Services, 7.01.557  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

21615, 21811, L8600

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

0577U, 0579U,  0581U, 0584U, 0587U, 0588U, 0589U, 0590U, 0591U, 0593U, 0594U, 0595U, 0598U, 0599U

Leadless Cardiac Pacemakers, 2.02.515  PBC | Premera HMO
Now requires review for medical necessity.

C1740

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

C1742

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.653  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J3403

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

C9305

Now requires review for medical necessity and prior authorization.

J3402

Pharmacologic Treatment of Clostridioides Difficile, 5.01.631  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

0780T

Pharmacologic Treatment of Hemophilia, 5.01.581  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J7173, J7174

Pharmacologic Prevention and Treatment of HIV/AIDS, 5.01.588  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J0738, J0752

Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers, 1.01.18  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

E0658

Now considered investigational.

E0659

Revised codes
Effective October 3, 2025

Alpha1-Proteinase Inhibitors, 5.01.624  PBC | Premera HMO
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J0491, J9332, J9334

CGRP Inhibitors for Migraine Prophylaxis, 5.01.584  PBC | Premera HMO 
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J3032

Drugs for Rare Diseases, 5.01.576  PBC | Premera HMO 
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J3241

IL-5 Inhibitors, 5.01.559  PBC | Premera HMO 
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J0517, J2182

Immune Checkpoint Inhibitors, 5.01.591  PBC | Premera HMO 
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J9022, J9024, J9173, J9272, J9289, J9622

Medical Pharmacologic Treatments of Multiple Sclerosis, 5.01.644  PBC | Premera HMO 
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J2351

Pharmacologic Treatment of Gout, 5.01.616  PBC | Premera HMO 
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J0638

Pharmacologic Treatment of Osteoporosis, 5.01.596  PBC | Premera HMO 
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J3111

No longer requires review for site of service. Review for medical necessity and prior authorization still required.

J0893

Systemic Pharmacologic Treatments of Plaque Psoriasis, 5.01.652  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J1747

Thymic Stromal Lymphopoietin (TSLP) Inhibitors, 5.01.627  PBC | Premera HMO 
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J2356

Xolair (omalizumab), 5.01.513  PBC | Premera HMO 
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J2357

Effective October 1, 2025

Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers, 1.01.18  PBC | Premera HMO 
No longer considered investigational. Now requires review for medical necessity and prior authorization.

E0656, E0657, E0670, E0678-E0682

Removed codes
Effective January 2, 2026

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

G0023, G0024

Effective October 1, 2025

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

C9174

Laboratory Testing Investigational Services, 2.04.520  PBC | Premera HMO
Code Terminated

0450U, 0451U

Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders, 5.01.620  PBC | Premera HMO
Code Terminated

J2503

No updates this month.

No updates this month.

No updates this month.

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
  • hrHPV-based screening triggers including immediate high-resolution anoscopyfor high risk (hr) Human Papillomavirus (HPV) -positive results (including HPV16+) and specific cytology/hrHPV combinations, even when cytology is negative for intraepithelial lesion or malignancy
• Contraindications added:
  • Patient-related limitations including the inability to tolerate the exam due to discomfort, anxiety, or apprehension
  • Clinical safety concerns including significant active bleeding or presence of a friable mass that could be damaged, bleed, or irritated by the rigid anoscope.

No updates this month.

No updates this month.

No updates this month.

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 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, 7.01.78  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