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 November 15, 2025

    Effective for dates of service on and after November 15, 2025, the following updates will apply to the Carelon MBM, 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 aligned with Carelon musculoskeletal (MSK) guidelines for labral tear-shoulder
    • Added x-ray per ACR AUC for chronic shoulder pain, alignment with MSK thresholds
    • Removal of operationally vague scenario for ligament and tendon injuries- wrist now addressed under unexplained pain not otherwise specified (NOS)
    • UE pain section combined with TFCC 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 aligned with MSK guideline
    • Alignment with Carelon MSK Joint surgery guideline thresholds for meniscal tear/injury
    • 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 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

    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 MBM, 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

    Polysomnography and Home Sleep Apnea Testing

    • Inclusion of devices using peripheral arterial tone as an alternative approach to home sleep apnea study
    • Age change to clarify non-adult patients at age 17 years and younger
    • Expanded criteria for suspected obstructive sleep apnea (OSA) when etiology is unclear (home and in-lab) while eliminating the contraindications (home only)
    • Clarifications for central sleep apnea and periodic limb movement disorder
    • Removal of age restriction from auto-titrating positive airway pressure (PAP) contraindications

    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 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 when criteria are met
    • Subcutaneous ICDs for individuals with an indication for ICD implantation when criteria are met

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

    • 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) moved from Pharmacologic Treatment of Psoriasis, 5.01.629 to Miscellaneous Pharmacologic Treatments of Psoriasis, 5.01.652

    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 for the treatment of postmenopausal osteoporosis, Paget’s disease of bone, and hypercalcemia

    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

     

    • Added 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)

    Prosthetic 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 change

    • 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 moved

    • 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

    Effective September 20, 2025

    Effective for dates of service on and after September 20, 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

    Prenatal Screening using Cell-free DNA

    • Clarified cell free DNA screening for fetal red blood cell antigens is considered not medically necessary

    Carrier Screening in the Reproductive Setting

    • Expanded carrier screening: Clarified that carrier screening for a single gene condition can also be medically necessary when criteria are met
    • Carrier testing based on family history: Expanded criteria to include having a relative who is a documented carrier of a genetic condition

    Genetic Testing for Inherited Conditions

    • New testing criteria for primary mitochondrial diseases includes mitochondrial DNA genomic sequence, large-deletion, and targeted nuclear mitochondrial gene panel analysis
    • Testing for retinal disorders is considered medically necessary when the general requirements or multi-gene panel criteria are met
    • Clarified weakly provoking factors for venous thromboembolism in thrombophilia testing

    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 September 5, 2025

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

    • Quzyttir (cetirizine) added to Antihistamines, Injection
    • Prialt (ziconotide) added to Chronic Pain Drugs
    • Visudyne (verteporfin) added to Photoenhancers, Injection
    • Veklury (remdesivir) added to SARS-CoV-2 Inhibitors, Infusion

    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
    • Pulsed field ablation incorporated into all medically necessary statements

    Revised medical policies
    Effective July 1, 2025

    Amniotic Membrane and Amniotic Fluid, 7.01.583 PBC | Premera HMO
    Device added

    • NuShield for the treatment of nonhealing diabetic lower-extremity ulcers

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

    • Obesity body mass index threshold for Asian populations added to selection criterion for bariatric surgery
    • 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

    Deep Brain Stimulation, 7.01.63  PBC | Premera HMO
    Investigational criteria added

    • Adaptive deep brain stimulation in Parkinson disease is considered investigational

    Revised pharmacy policies
    Effective July 1, 2025

    Antibody-Drug Conjugates, 5.01.582 PBC | Premera HMO
    Medical necessity criteria added

    • Adcetris (brentuximab vedotin) and Polivy (polatuzumab vedotin-piiq) moved from policy Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502 to Antibody-Drug Conjugate, 5.01.582
    • Datroway (datopotamab deruxtecan-dlnk) for the treatment of unresectable or metastatic, hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer 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

    Antidepressants: Pharmacy Medical Necessity Criteria for Brands, 5.01.520 PBC | Premera HMO
    Medical necessity criteria added

    • Raldesy (trazodone oral solution) for the treatment of depression when criteria are met

    BCR-ABL Kinase Inhibitors, 5.01.518 PBC | Premera HMO
    Medical necessity criteria updated

    • Scemblix (asciminib) criteria updated to include all previously treated individuals

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

    • Soliris (eculizumab) criteria updated for the treatment of generalized myasthenia gravis from aged 18 years or older to aged 6 years or older

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

    • Nexviazyme criteria updated the maximum dose prescribed
    • Rivfloza (nedosiran) criteria updated to manage urinary oxalate levels in individuals aged 2 years and older, and the recommended dosing has been revised for those aged 2 to 11 years

    Medical necessity criteria added

    • Vykat XR (diazoxide choline extended-release) for the treatment of hyperphagia in individuals with Prader-Willi syndrome when criteria are met
    • Ctexli (chenodiol) added for the treatment of cerebrotendinous xanthomatosis when criteria are met

    Dupixent (dupilumab), 5.01.575  PBC | Premera HMO
    Medical necessity criteria updated

    • Asthma criteria updated to:
      • Include a forced expiratory volume in 1 second (FEV1)/ forced vital capacity (FVC) less than 0.80 as an optional requirement
      • Replace ‘has a dependence on oral corticosteroids of at least 5 mg per day of prednisone or equivalent’ with ‘has asthma that worsens upon tapering of oral corticosteroid therapy’

    Medical necessity criteria added

    • Indication added for the treatment of chronic spontaneous urticaria when criteria are met

    Hereditary Angioedema, 5.01.587  PBC | Premera HMO
    Medical necessity criteria updated

    • Berinert (pdC1-INH), Firazyr (icatibant), Kalbitor (ecallantide), and Ruconest criteria updated to clarify that the generic icatibant step therapy requirement applies to individuals aged 18 years or older who are not currently pregnant
    • Sajazir (icatibant) updated from a preferred treatment to a non-preferred agent for acute attacks of hereditary angioedema

    IL-5 Inhibitors, 5.01.559  PBC | Premera HMO
    Thymic Stromal Lymphopoietin (TSLP) Inhibitors, 5.01.627
      PBC | Premera HMO
    Xolair (omalizumab), 5.01.513
      PBC | Premera HMO
    Medical necessity criteria updated

    • Asthma criteria updated to:
      • Include a forced expiratory volume in 1 second (FEV1)/ forced vital capacity (FVC) less than 0.80 as an optional requirement
      • Replace ‘has a dependence on oral corticosteroids of at least 5 mg per day of prednisone or equivalent’ with ‘has asthma that worsens upon tapering of oral corticosteroid therapy’

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

    • Yervoy criteria updated for the treatment of microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) unresectable or metastatic colorectal cancer (CRC) allowing coverage for all lines of therapy when used in combination with Opdivo
    • Opdivo criteria updated for the treatment of MSI-H or dMMR unresectable or metastatic CRC allowing coverage for all lines of therapy when used in combination with Yervoy

    Medical necessity criteria added

    • Yervoy (ipilimumab) indication added for the first-line treatment of unresectable or metastatic hepatocellular carcinoma (HCC) when used in combination with Opdivo (nivolumab) when criteria are met
    • Opdivo (nivolumab) indication added for the first-line treatment of unresectable or metastatic HCC when used in combination with Yervoy (ipilimumab) when criteria are met
    • Imfinzi (durvalumab) indication added for the treatment of muscle invasive bladder cancer when criteria are met

    Immune Globulin Therapy, 8.01.503  PBC | Premera HMO
    Medical necessity criteria added

    • Measles post-exposure prophylaxis treatment

    Multiple Receptor Tyrosine Kinase Inhibitors, 5.01.534  PBC | Premera HMO
    Medical necessity criteria updated

    • Cabometyx (cabozantinib) criteria updated to include treatment of pancreatic neuroendocrine tumors and extra-pancreatic neuroendocrine tumors when criteria are met

    Pharmacologic Treatment of Benign Prostatic Hyperplasia, 5.01.545  PBC | Premera HMO
    Medical necessity criteria added

    • Cardura (doxazosin) added for the treatment of benign prostatic hyperplasia (BPH) and hypertension when criteria are met
    • Cardura XL (doxazosin extended-release) added for the treatment of BPH when criteria are met

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

    • Colcrys (colchicine) added to the list of gout drugs that require the individual has tried generic oral colchicine or generic oral allopurinol first and had an inadequate response

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

    • Calcitonin salmon nasal spray for the treatment of postmenopausal osteoporosis

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

    • Onapgo (apomorphine) added for the treatment of motor fluctuations in individuals with advanced Parkinson’s disease when criteria are met

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

    • Criteria added for Imuldosa (ustekinumab-srlf), Otulfi (ustekinumab-aauz), Pyzchiva (ustekinumab-ttwe), Selarsdi (ustekinumab-ackn), Steqeyma (ustekinumab-stba), ustekinumab (Stelara unbranded), ustekinumab-aekn (Selarsdi unbranded), ustekinumab-ttwe (Pyzchiva unbranded), Yesintek (ustekinumab-kfce), and Wezlana (ustekinumab-auub)

    Note updated

    • Criteria for Bimzelx (bimekizumab-bkzx), Cimzia (certolizumab pegol), Cosentyx (secukinumab), Ilumya (tildrakizumab-asmn), and Siliq (brodalumab) do not apply to one Open formulary (Formulary ID: 6062; Rx Plan F1) and one Preferred formulary (Formulary ID: 6064; Rx Plan G3), applicable criteria can be found in the Medical Necessity Criteria for Custom Open and Preferred Formularies, 5.01.647

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

    • The following medically necessary criteria (when criteria are met) and drugs were moved from Pharmacotherapy of Arthropathies, 5.01.550 to Pharmacologic Treatment of Psoriatic Arthritis, 5.01.645: Psoriatic arthritis criteria for infliximab products, adalimumab products, Simponi Aria, Enbrel, Taltz, Stelara, Skyrizi, Tremfya, Rinvoq, Rinvoq LQ, Xeljanz, Xeljanz XR, Otezla, Cimzia, Simponi, Bimzelx, Cosentyx, and Orencia
    • Medically nescessary criteria added for Imuldosa (ustekinumab-srlf), Otulfi (ustekinumab-aauz), Pyzchiva (ustekinumab-ttwe), Selarsdi (ustekinumab-ackn), Steqeyma (ustekinumab-stba), ustekinumab (Stelara unbranded), ustekinumab-aekn (Selarsdi unbranded), ustekinumab-ttwe (Pyzchiva unbranded), Yesintek (ustekinumab-kfce), and Wezlana (ustekinumab-auub)

    Note updated

    • Criteria for Bimzelx (bimekizumab-bkzx), Cimzia (certolizumab pegol), Cosentyx (secukinumab) IV/SC, Orencia (abatacept) IV/SC, and Simponi (golimumab) SC do not apply to one Open formulary (Formulary ID: 6062; Rx Plan F1) and one Preferred formulary (Formulary ID: 6064; Rx Plan G3), applicable criteria can be found in the Medical Necessity Criteria for Custom Open and Preferred Formularies, 5.01.647

    Pharmacologic Treatment of Sleep Disorders, 5.01.599  PBC | Premera HMO
    Medical necessity criteria updated

    • Lumryz (sodium oxybate) criteria updated age requirement from 18 years or older to 7 years or older
    • Lumryz (sodium oxybate), brand sodium oxybate, Wakix (pitolisant), Xyrem (sodium oxybate), and Xywav (calcium, magnesium, potassium, and sodium oxybates) cataplexy criteria updated to clarify that cataplexy is documented by brief episodes of sudden bilateral loss of muscle tone with maintained consciousness that is precipitated by an emotional trigger such as laughter or joking rather than laughter and joking specifically
    • Lumryz (sodium oxybate) excessive daytime sleepiness criteria updated to include an age requirement of 7 years or older
    • Sunosi (solriamfetol) and Wakix (pitolisant) excessive daytime sleepiness criteria updated to include an age requirement of 18 years or older
    • Brand sodium oxybate, Xyrem (sodium oxybate), and Xywav (calcium, magnesium, potassium, and sodium oxybates) excessive daytime sleepiness criteria updated to include an age requirement of 7 years or older

    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 Transthyretin-Mediated Amyloidosis, 5.01.593  PBC | Premera HMO
    Medical necessity criteria added

    • Amvuttra (vutrisiran) indication added for the treatment of cardiomyopathy of wild type or hereditary transthyretin-mediated amyloidosis when criteria are met

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

    • Psoriatic arthritis criteria for infliximab products, adalimumab products, Simponi Aria, Enbrel, Taltz, Stelara, Skyrizi, Tremfya, Rinvoq, Rinvoq LQ, Xeljanz, Xeljanz XR, Otezla, Cimzia, Simponi, Bimzelx, Cosentyx, and Orencia moved from Pharmacotherapy of Arthropathies, 5.01.550 to Pharmacologic Treatment of Psoriatic Arthritis, 5.01.645

    Note updated

    • Criteria for Actemra (tocilizumab) IV/SC, Bimzelx (bimekizumab-bkzx), Cimzia (certolizumab pegol), Cosentyx (secukinumab), Kevzara (sarilumab), Kineret (anakinra), Olumiant (baricitinib), Orencia (abatacept), Simponi (golimumab) SC, Tofidence (tocilizumab-bavi) IV, Tyenne (tocilizumab-aazg) IV/SC do not apply to one Open formulary (Formulary ID: 6062; Rx Plan F1) and one Preferred formulary (Formulary ID: 6064; Rx Plan G3), applicable criteria can be found in the Medical Necessity Criteria for Custom Open and Preferred Formularies, 5.01.647

    Pharmacotherapy of Type I and Type II Diabetes Mellitus, 5.01.569  PBC | Premera HMO
    Medical necessity criteria updated

    • Victoza (liraglutide) updated from a preferred to a non-preferred GLP-1 agonist

    Medical necessity criteria added

    • Brynovin (sitagliptin) added as a non-preferred DPP-4 inhibitor
    • Generic liraglutide added as a preferred GLP-1 agonist

    Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  PBC | Premera HMO
    Rituximab: Non-oncologic and Miscellaneous Uses, 5.01.556
      PBC | Premera HMO
    Note updated

    • Criteria do not apply to one Open formulary (Formulary ID: 6062; Rx Plan F1) and one Preferred formulary (Formulary ID: 6064; Rx Plan G3), applicable criteria can be found in the Medical Necessity Criteria for Custom Open and Preferred Formularies, 5.01.647

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  PBC | Premera HMO
    Note updated

    • Criteria for Cimzia (certolizumab pegol), Entyvio (vedolizumab) SC, Simponi (golimumab) SC, and Zeposia (ozanimod) do not apply to one Open formulary (Formulary ID: 6062; Rx Plan F1) and one Preferred formulary (Formulary ID: 6064; Rx Plan G3), applicable criteria can be found in the Medical Necessity Criteria for Custom Open and Preferred Formularies, 5.01.647

    Medical necessity criteria

    • Criteria added for Imuldosa (ustekinumab-srlf), Otulfi (ustekinumab-aauz), Pyzchiva (ustekinumab-ttwe), Selarsdi (ustekinumab-ackn), Steqeyma (ustekinumab-stba), ustekinumab (Stelara unbranded), ustekinumab-aekn (Selarsdi unbranded), ustekinumab-ttwe (Pyzchiva unbranded), Yesintek (ustekinumab-kfce), and Wezlana (ustekinumab-auub)

    Prostate Cancer Targeted Therapies, 5.01.544  PBC | Premera HMO
    Medical necessity criteria added

    • Abirtega (abiraterone) added with identical criteria to generic abiraterone

    No updates this month.

    No updates this month.

    Added codes
    Effective October 3, 2025

    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 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

    Prosthetic 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

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

    J1747

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

    0964T, 0965T, 0966T

    Effective September 5, 2025

    Bioengineered Skin and Soft Tissue Substitutes, 7.01.582  PBC | Premera HMO
    Now requires review for investigational.

    C1763

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

    S0145

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

    J0248, J1201, J2278, J3396

    Myoelectric Prosthetic and Orthotic Components for the Upper Limb, 1.04.502  PBC | Premera HMO
    Now requires review for medical necessity and prior authorization.

    L6882

    Effective August 1, 2025

    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 July 3, 2025

    Catheter Ablation for Atrial Fibrillation, 2.02.516  PBC | Premera HMO
    Now requires review for medical necessity and prior authorization.

    93655, 93656, 93657

    Effective July 1, 2025

    Amniotic Membrane and Amniotic Fluid, 7.01.583  PBC | Premera HMO
    Now requires review for investigational.

    Q4368, Q4369, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382

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

    C9174

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

    J9276, J9382

    Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma, 8.01.63  PBC | Premera HMO
    Now requires review for medical necessity and prior authorization.

    Q2058

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

    0568U

    Focal Treatments for Prostate Cancer, 8.01.61  PBC | Premera HMO
    Now requires review for investigational.

    0950T

    Gene Therapies for Rare Diseases, 5.01.642  PBC | Premera HMO
    Now requires review for medical necessity and prior authorization.

    J3391

    Immune Checkpoint Inhibitors, 5.01.591  PBC | Premera HMO
    Now requires review for medical necessity and prior authorization.

    J9275, J9289

    Laboratory Testing Investigational Services, 2.04.520  PBC | Premera HMO
    Now requires review for investigational.

    0558U, 0559U, 0563U, 0564U, 0570U, 0572U, 0573U, 0574U

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

    J1326, J9341, J9174

    Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis, 2.04.127  PBC | Premera HMO
    Now requires review for investigational.

    0557U

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

    0948T, 0949T, 0956T, 0957T, 0958T, 0959T, 0960T, 0961T, 0962T, 0964T, 0965T, 0966T, 0967T, 0968T, 0969T, 0970T, 0971T, 0972T, 0973T, 0974T, 0975T, 0976T, 0978T, 0979T, 0980T, 0981T, 0982T, 0983T, 0984T, 0985T, 0986T, 0987T, C8005

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

    A6610, E0201, E1022, E1023

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

    J7172

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

    J7356

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

    Q9997

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563 PBC | Premera HMO
    Pharmacologic Treatment of Psoriasis, 5.01.629
      PBC | Premera HMO
    Pharmacologic Treatment of Psoriatic Arthritis, 5.01.645
      PBC | Premera HMO
    Now requires review for medical necessity and prior authorization.

    Q5098, Q5099, Q5100, Q5137, Q5138, Q9996, Q9998, Q9999

    Semi-Implantable and Fully Implantable Middle Ear Hearing Aids, 7.01.84  PBC | Premera HMO
    Now requires review for investigational.

    0951T, 0952T, 0953T, 0954T, 0955T

    Site of Service: Select Surgical Procedures, 11.01.524  PBC | Premera HMO
    Now requires review for medical necessity, including site of service and prior authorization.

    31233, 31235, 31240

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

    0552U, 0553U, 0554U, 0555U, 0560U, 0561U, 0562U, 0565U, 0566U, 0567U, 0569U, 0571U

    Revised codes
    Effective October 3, 2025

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

    J3241

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

    J9024, J9173, J9272, J9289, J9622

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

    J0638

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

    J2351

    Pharmacologic Treatment of Osteoporosis, 5.01.596 PBC | Premera HMO
    Now requires review for site of service. Currently requires 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

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

    J2356

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

    J2357

    Removed codes
    Effective July 1, 2025

    Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma, 8.01.63  PBC | Premera HMO
    Code terminated

    C9301

    Gonadotropin Releasing Hormone (GnRH) Analogs, 5.01.625  PBC | Premera HMO
    Code terminated

    J9225

    Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
    Code terminated

    C9303

    Pharmacologic Treatment of Hemophilia, 5.01.581  PBC | Premera HMO
    Code terminated

    C9304

    Use of Granulocyte Colony-Stimulating Factors (G-CSF), 5.01.551  PBC | Premera HMO
    Code terminated

    C9173

  • Updates for only non-individual plans

  • Effective September 5, 2025

    InterQual Criteria

    The Plan will begin using InterQual criteria to determine the appropriate level of care for all planned procedures. Criteria within medical policy Site of Service: Select Surgical Procedures, 11.01.524, will continue to apply to the procedures listed within that policy. Prior authorization for all inpatient hospital care (surgical, non-surgical, behavioral health and/or substance abuse) continues to be required.

    No updates this month.

    No updates this month.

    No updates this month.

  • 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.

    No updates this month.

  • 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

    No updates this month.

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