Medical Policy and Coding Updates

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    We regularly review policies to make sure they’re consistent with the latest medical evidence. We'd like your feedback on policies scheduled for review. In the document, you can open any title to read the current policy. Email us your policy comments or suggestions today!

  • Updates for both non-individual and individual plans

  • Effective August 1, 2025

    Effective for dates of service on and after August 1, 2025, the following update will apply to the Carelon Medical Benefits Management (MBM) Genetic Testing Program. The date of service (DOS) will be defined as the sample or collection date. For archival samples, the sample collection or retrieval date will serve as the DOS for review. In the rare circumstance that an exception is needed, providers may reach out to the Carelon MBM genetic testing team at DL-GeneticTestingSolution@carelon.com.

    This update is focused on providing clinically appropriate, safe, and affordable health care services. Providers are reminded that they may submit authorization requests through the Carelon provider portal. Portal access is available 24/7 to process requests in real-time and is the fastest, most convenient way to request an authorization.

    Effective July 26, 2025

    Effective for dates of service on and after July 26, 2025, the following updates will apply to the Carelon MBM, 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

    Chromosomal Microarray Analysis

    • Postnatal/Pediatric evaluation now includes neonatal death as an indication for chromosomal microarray analysis
    • Optical Genome Mapping considered not medically necessary; more studies are needed to validate its use for structural variant analysis

    Whole Exome Sequencing and Whole Exome Sequencing

    • Clarified and restructured criteria for better readability
    • Specified that whole exome sequencing is excluded for early neonatal death

    Pharmacogenomic Testing

    • Genotyping for biomarkers in Table 1 is medically necessary when conditions are met
    • Clarified Table 1 title:
      • Therapies and associated biomarkers considered medically necessary for genotyping
    • Biomarkers added to Table 1:
      • Donanemab-azbt added for genotyping ApoE ε4 in Neurology for Alzheimer's treatment
      • Deuruxolitinib added for genotyping CYP2C9 in Dermatology for alopecia areata treatment
      • NUDT15 risk allele added to explain thiopurine-related myelosuppression risk in Asians and Hispanics
    • Eliglustat's therapeutic area is clarified as hematology, not pediatrics

    Predictive and Prognostic Polygenic Testing

    • Guideline reaffirmed; Description/Scope and Rationale edited

    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 July 3, 2025

    Bioengineered Skin and Soft Tissue Substitutes, 7.01.582  PBC | Premera HMO
    Policy renumbered

    • This policy replaces Bioengineered Skin and Soft Tissue Substitutes, 7.01.113, which will be deleted following 90-day provider notification

    Investigational device added

    • BEAR (bridge-enhanced anterior cruciate ligament repair) implant added to investigational list

    Catheter Ablation for Atrial Fibrillation, 2.02.516  PBC | Premera HMO
    New policy

    • Transcatheter radiofrequency ablation or cryoablation to treat atrial fibrillation may be considered medically necessary when criteria are met

    Effective July 1, 2025

    Pharmacologic Treatment of Psoriasis, 5.01.629  PBC | Premera HMO

    Pharmacotherapy of Arthropathies, 5.01.550  PBC | Premera HMO

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  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
    Medical necessity criteria added/updated

    • Humira (adalimumab) (AbbVie) [NDCs starting with 00074] updated from a preferred to a non-preferred adalimumab product

    Use of Granulocyte Colony-Stimulating Factors (G-CSF), 5.01.551  PBC | Premera HMO
    Medical necessity criteria updated

    • Udenyca (pegfilgrastim-cbqv) and Udenyca Onbody (pegfilgrastim-cbqv) moved from second-line to first-line therapy for individuals younger than 18 years of age
    • Udenyca (pegfilgrastim-cbqv) and Udenyca Onbody (pegfilgrastim-cbqv) moved from third-line to second-line therapy for individuals aged 18 years and older
    • Nyvepria (pegfilgrastim-apgf) moved from first-line to second-line therapy for individuals younger than 18 years of age
    • Nyvepria (pegfilgrastim-apgf) moved from second-line to third-line therapy for individuals aged 18 years and older

    Effective June 6, 2025

    Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis, 2.04.127  PBC | Premera HMO
    New policy

    • Multitarget polymerase chain reaction testing for the diagnosis of bacterial vaginosis is considered investigational

    Effective May 6, 2025

    Carpal Tunnel Release Surgical Treatments, 7.01.595  PBC | Premera HMO
    New policy

    • Carpal tunnel release surgery is considered medically necessary for individuals with carpal tunnel syndrome who have failed conservative therapy when criteria are met

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

    • Aveed (testosterone undecanoate) and Testopel (testosterone pellets) updated to match criteria for all other brand testosterone products

    Pharmacologic Treatment of Transthyretin-Mediated Amyloidosis, 5.01.593  PBC | Premera HMO
    Medical necessity criteria updated

    • Amvuttra, Onpattro, and Wainua updated diagnostic criteria

    Pharmacotherapy of Arthropathies, 5.01.550  PBC | Premera HMO

    Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  PBC | Premera HMO

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523  PBC | Premera HMO
    Medical necessity criteria added

    • Tyenne (tocilizumab-aazg) IV added to site of service review

    New medical policies
    Effective May 1, 2025

    Radiofrequency Volumetric Tissue Reduction for Nasal Obstruction, 7.01.597  PBC | Premera HMO
    New policy

    • Radiofrequency volumetric tissue reduction for nasal obstruction due to internal nasal valve collapse is considered investigational. (e.g., VivAer Stylus)
    • Radiofrequency ablation or cryoablation for nasal swell body reduction for the treatment of nasal obstruction is considered investigational

    Revised medical policies
    Effective May 1, 2025

    Skilled Hourly Nursing Care in the Home, 11.01.522  PBC | Premera HMO
    Medical necessity criteria added

    • Continuation of care now requires that skilled hourly nursing care is documented in the nursing progress notes and the physician reviews and renews the treatment plan, including discharge planning, every six months

    New pharmacy policies
    Effective May 1, 2025

    Bispecific Antibodies, 5.01.650  PBC | Premera HMO
    New policy

    • Rybrevant (amivantamab-vmjw) moved from Epidermal Growth Factor Receptor (EGFR) Inhibitors 5.01.603 to policy 5.01.650 Bispecific Antibodies
    • Columvi (glofitamab-gxbm), Epkinly (epcoritamab-bysp), Lunsumio (mosunetuzumab-axgb) moved from Monoclonal Antibodies for the Treatment of Lymphoma 2.03.502 to Bispecific Antibodies 5.01.650
    • Blincyto (blinatumomab), Elrexfio (elranatamab-bcmm), Imdelltra (tarlatamab-dlle), Talvey (talquetamab-tgvs), and Tecvayli (teclistamab-cqyv) moved from Miscellaneous Oncology Drugs 5.01.540 to Bispecific Antibodies 5.01.650
      • Blincyto (blinatumomab) coverage criteria to include treatment of standard or high-risk B-cell ALL in pediatric individuals
    • Bizengri (zenocutuzumab-zbco) for the treatment of advanced, unresectable, or metastatic pancreatic adenocarcinoma or non-small cell lung cancer when criteria are met
    • Ziihera (zanidatamab-hrii) for the treatment of biliary tract cancer when criteria are met

    Revised pharmacy policies
    Effective May 1, 2025

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

    • Braftovi (encorafenib) in combination with Erbitux (cetuximab) and mFOLFOX6 for the treatment of metastatic colorectal cancer

    Drug/medical necessity criteria added

    • Gomekli (mirdametinib) for the treatment of neurofibromatosis type 1 when criteria are met

    Investigational criteria added

    • Clarified that the medications listed in this policy are subject to the product's FDA dosage and administration prescribing information

    Length of approval criteria added

    • Non-formulary exception review authorizations for all drugs listed in this policy may be approved up to 12 months

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

    • Imcivree (setmelanotide) criteria age requirement changed from 6 years to 2 years of age and older

    Drug/medical necessity criteria added

    • Crenessity (crinecerfont) for the treatment of congenital adrenal hyperplasia when criteria are met

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

    • Tevimbra (tislelizumab-jsgr) for the first-line treatment of esophageal cancer when criteria are met

    Intravitreal and Suprachoroidal Corticosteroids, 5.01.619 PBC | Premera HMO
    Medical necessity criteria updated

    • Iluvien (fluocinolone acetonide intravitreal implant) for the treatment of chronic non-infectious uveitis affecting the posterior segment of the eye when criteria are met

    Investigational criteria added

    • Clarified that the medications listed in this policy are subject to the product's FDA dosage and administration prescribing information

    Length of approval criteria added

    • Non-formulary exception review authorizations for all drugs listed in this policy may be approved up to 12 months

    Medical Necessity Criteria and Dispensing Quantity Limits for Metallic Formulary Benefits, 5.01.547 PBC | Premera HMO
    Title change

    • Updated the policy title from “Medical Necessity Criteria and Dispensing Quantity Limits for Exchange Formulary Benefits” to “Medical Necessity Criteria and Dispensing Quantity Limits for Metallic Formulary Benefits.”

    Section removed

    • ‘Step Therapy Protocol’ and ‘Drugs Subject to the Step Therapy Protocol’ removed

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

    • Zunveyl (benzgalantamine) for the treatment of mild to moderate dementia of Alzheimer’s disease when criteria are met
    • Flagyl (metronidazole) and Likmez (metronidazole) added to Antibiotics
    • Venxxiva (tiopronin delayed-release) added to Cystine Binding Drugs
    • Brand metaxalone added to Muscle Relaxants
    • PR benzoyl peroxide 7% wash and MetroLotion (metronidazole lotion) added to Brand Topical Acne or Rosacea Agents
    • Rocaltrol (calcitriol) oral solution added to Vitamin Agents
    • Azmiro (testosterone cypionate) added to Testosterone Replacement Products

    Drug/medical necessity criteria removed

    • Evekeo ODT removed from brand ADHD Drugs as the product has been discontinued
    • Dexonto (dexamethasone) removed from Brand Topical Corticosteroids

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

    • Corrected policy language for drugs with additional quantities from “at least 30 doses per 30 days” to “less than 30 doses per 30 days”

    Drug/medical necessity criteria updated

    • Symbravo (rizatriptan/meloxicam) for the acute treatment of migraine headaches when criteria are met

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

    • Tabloid (thioguanine) criteria updated to include treatment of acute lymphoblastic leukemia
    • Dacogen (decitabine) and generic decitabine coverage criteria to include treatment of acute myeloid leukemia

    Drug/medical necessity criteria added

    • Revuforj (revumenib) for the treatment of acute leukemia when criteria are met
    • Romvimza (vimseltinib) for the treatment of tenosynovial giant cell tumor when criteria are met
    • Beizray (docetaxel) for the treatment of various cancers, including breast cancer, non-small cell lung cancer, prostate cancer, gastric adenocarcinoma, and squamous cell carcinoma of the head and neck when criteria are met

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

    • Polivy (polatuzumab vedotin-piiq) criteria to include use as bridging therapy prior to a planned CD-19 CAR-T treatment when criteria are met

    Pharmacologic Treatment of Cystic Fibrosis, 5.01.539  PBC | Premera HMO
    Title change

    • Policy title changed from “Pharmacologic Treatment of Cystic Fibrosis with Ivacaftor Products” to “Pharmacologic Treatment of Cystic Fibrosis.”

    Drug/medical necessity criteria added

    • Alyftrek (vanzacaftor/tezacaftor/ deutivacaftor) for the treatment of cystic fibrosis (CF) when criteria are met

    Medical necessity criteria updated

    • Clarified that the following drugs cannot be used in combination: Alyftrek (vanzacaftor/tezacaftor/ deutivacaftor), Kalydeco (ivacaftor), Orkambi (lumacaftor/ivacaftor), Symdeko (tezacaftor/ivacaftor), and Trikafta (elexacaftor/tezacaftor/ivacaftor)
    • Trikafta (elexacaftor/ tezacaftor/ivacaftor) for the treatment of CF who have a mutation that is responsive to Trikafta based on clinical and/or in vitro data when criteria are met
    • Quantity limits added per the prescribing information for Kalydeco (ivacaftor), Orkambi (lumacaftor/ivacaftor), Symdeko (tezacaftor/ivacaftor), and Trikafta (elexacaftor/tezacaftor/ivacaftor)

    Investigational criteria added

    • Clarified that the medications listed in this policy are subject to the product's FDA dosage and administration prescribing information

    Length of approval criteria added

    • Non-formulary exception review authorizations for all drugs listed in this policy may be approved up to 12 months

    Pharmacologic Treatment of Hemophilia, 5.01.581  PBC | Premera HMO
    Drug/medical necessity criteria added

    • Alhemo (concizumab-mtci) for the treatment of hemophilia A and hemophilia B when criteria are met
    • Qfitlia (fitusiran) for the treatment of hemophilia A and hemophilia B when criteria are met

    Medical necessity criteria removed

    • Beqvez (fidanacogene elaparvovec-dzkt) removed from policy as the product has been discontinued

    Pharmacologic Treatment of High Cholesterol, 5.01.558  PBC | Premera HMO

    Pharmacologic Treatment of Psoriasis, 5.01.629  PBC | Premera HMO
    Length of approval criteria updated

    • Re-authorization duration of approval changed from 3 years to 12 months

    Pharmacologic Treatment of Sickle Cell Disease, 5.01.640  PBC | Premera HMO
    Drug/medical necessity criteria added

    • Xromi (hydroxyurea) to reduce the frequency of painful crises and reduce the need for blood transfusions in individuals with sickle cell anemia with recurrent moderate to severe painful crises when criteria are met

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

    • Adalimumab products, Enbrel (etanercept), Simponi Aria (golimumab), tocilizumab products, Kevzara (sarilumab), Orencia (abatacept), and Cimzia (certolizumab pegol) polyarticular juvenile idiopathic arthritis (PJIA) criteria updated to require that the individual has aggressive disease
    • Tocilizumab products PJIA and rheumatoid arthritis criteria updated to add an exception to the brand step therapy requirement if the individual has heart failure or a previously treated lymphoproliferative disorder
    • Kevzara (sarilumab) rheumatoid arthritis criteria updated to add an exception to the brand step therapy requirement if the individual has heart failure or a previously treated lymphoproliferative disorder
    • Orencia (abatacept) psoriatic arthritis, rheumatoid arthritis, and PJIA criteria updated to add an exception to the brand step therapy requirement if the individual has heart failure, a previously treated lymphoproliferative disorder, a previous serious infection, or a demyelinating disorder
    • Kevzara (sarilumab) PJIA criteria updated to add an exception to the brand step therapy requirement if the individual has heart failure, a previously treated lymphoproliferative disorder, a previous serious infection, or a demyelinating disorder

    Length of approval criteria updated

    • Re-authorization duration of approval changed from 3 years to 12 months

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  PBC | Premera HMO
    Drugs/medical necessity criteria added

    • Omvoh (mirikizumab-mrkz) IV/SC and Tremfya (guselkumab) IV/SC for the treatment of moderately to severely active Crohn’s disease when criteria are met

    Length of approval criteria updated

    • Re-authorization duration of approval changed from 3 years to 12 months

    SGLT2 Inhibitors, 5.01.646  PBC | Premera HMO
    New formatting

    • Section 1 includes coverage criteria for Incentive, Open, and Select formulary plans (Rx Plan A1, A2, B3, B4, C4, F1, and G3) and plans with no pharmacy benefit coverage
    • Section 2 includes separate coverage criteria for Essentials Formulary (Rx plan E1, E3, E4, M1, M2, and M4) plans
    • Section 3 includes separate coverage criteria for the Metallic (individual/small group/student ISHIP) plans

    Length of approval criteria updated

    • Re-authorization duration of approval changed from 3 years to 12 months

    No updates this month.

    No updates this month.

    Added codes
    Effective August 1, 2025

    Hepatitis C Antiviral Therapy, 5.01.606  PBC | Premera HMO
    Now requires review for medical necessity and prior authorization.

    S0145

    Implantable Bone-Conduction and Bone-Anchored Hearing Aids, 7.01.547  PBC | Premera HMO
    Now requires review for medical necessity and prior authorization. 

    69719

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

    J0893

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

    J0630

    Effective May 6, 2025

    Carpal Tunnel Release Surgical Treatments, 7.01.595  PBC | Premera HMO
    Now requires review for medical necessity and prior authorization.

    29848, 64721

    Effective May 1, 2025

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

    J1072

    Sinus Surgery in Adults, 7.01.559  PBC | Premera HMO
    Now requires review for medical necessity, including site of service and prior authorization.

    31233, 31235, 31240

    Revised codes
    Effective May 6, 2025

    Pharmacotherapy of Arthropathies, 5.01.550  PBC | Premera HMO
    Now requires review for site of service. Currently requires review for medical necessity and prior authorization.

    Q5135

    Removed codes
    Effective May 1, 2025

    Cochlear Implant, 7.01.586  PBC | Premera HMO

    Implantable Bone-Conduction and Bone-Anchored Hearing Aids, 7.01.547  PBC | Premera HMO
    No longer requires review.

    L8625

    Nonpharmacologic Treatment of Hyperhidrosis, 8.01.519  PBC | Premera HMO
    No longer requires review.

    11450, 11451

    Pharmacologic Treatment of Hemophilia, 5.01.581  PBC | Premera HMO
    No longer requires review.

    J1414

  • Updates for only non-individual plans

  • No updates this month.

    No updates this month.

    No updates this month.

    Removed codes
    Effective May 1, 2025

    EviCore Musculoskeletal: Therapies
    No longer requires review.

    97139, 97164

  • Updates for only individual plans

  • Effective July 3, 2025

    Updates to Prior Authorization for Therapy Services

    • Prior authorization will be required for physical and occupational therapy services:
      • Applicable to seventh visit onwards
      • The initial six visits do not require review
    • These services will continue to be reviewed using InterQual criteria

    No updates this month.

    No updates this month.

    Removed codes
    Effective May 1, 2025

    InterQual - General Surgery
    No longer requires review.

    34709, 34711, 34713, 34714, 34715

    InterQual - Orthoses, Thoracic, Lumbar and Sacral Spine
    No longer requires review.

    L0621, L0622, L0623, L0624

  • Updates for federal employee plans only

  • Effective July 3, 2025

    Catheter Ablation for Atrial Fibrillation, 2.02.516  PBC
    New policy

    • Transcatheter radiofrequency ablation or cryoablation to treat atrial fibrillation may be considered medically necessary when criteria are met

    Effective May 6, 2025

    Carpal Tunnel Release Surgical Treatments, 7.01.595  PBC
    New policy

    • Carpal tunnel release is considered medically necessary for individuals with carpal tunnel syndrome who have failed conservative therapy when criteria are met

    Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease, 7.01.594  PBC
    New policy

    • Percutaneous revascularization procedures may be considered medically necessary for the treatment of chronic symptomatic lower extremity peripheral arterial disease (PAD) with guideline-based criteria, chronic limb-threatening ischemia, and acute limb ischemia
    • Percutaneous revascularization procedures are considered not medically necessary for the treatment of asymptomatic lower extremity PAD
    • Percutaneous revascularization procedures using lithotripsy is considered investigational for the treatment of lower extremity PAD

    No updates this month.

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