All Insurance Policy Changes (Page 95)

Continuing from page 94. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

High impact
Positron Emission Tomography (PET) - Non-Oncologic Applications 6.01.07
Excellus BlueCross BlueShield·Effective May 15, 2026
Excellus BlueCross BlueShield has established a comprehensive medical policy for PET imaging in non-oncologic applications, effective May 15, 2026. This policy defines specific clinical criteria and appropriate use for PET/CT imaging across multiple body systems (abdominal, cardiac, chest, musculoskeletal, spine, and vascular) while designating certain uses as not medically appropriate or investigational. Billing teams must ensure prior authorization requests and claims align with the detailed indication-specific criteria outlined in this policy.
High impact
Positron Emission Tomography (PET) - Non-Oncologic Applications - (Effective Date - 2026-10-15) 6.01.07
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has issued a comprehensive new medical policy (effective October 15, 2026) establishing coverage criteria for PET imaging in non-oncologic applications, including abdominal imaging, cardiac imaging, prosthetic valve endocarditis assessment, and LVAD infections. This policy requires strict adherence to specific clinical indications and documentation requirements for coverage eligibility. Billing teams must implement prior authorization protocols and ensure provider documentation aligns with the detailed medical necessity criteria outlined.
High impact
Positive Airway Pressure Devices CPAP BiPAP APAP and Noninvasive Positive Pressure Ventilators (NIV) 1.01.06
Excellus BlueCross BlueShield·Effective Jul 17, 2025
Excellus BlueCross BlueShield has issued a comprehensive update to its policy on Positive Airway Pressure (PAP) devices covering CPAP, APAP, BPAP, and NIPPV effective July 17, 2025. The policy establishes new clinical criteria for initial 90-day trials, continuation coverage requirements (70% nightly use, 4+ hours per 24-hour period), device replacement standards, and specific indications for each device type. Billing teams must verify medical necessity documentation, compliance metrics, and device failure justification before processing claims for these sleep medicine devices.
High impact
Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty - (Effective Date - 2026-10-15) 6.01.17
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has updated its vertebroplasty/kyphoplasty policy (effective October 15, 2026) with stricter medical necessity criteria for non-malignant conditions, requiring 4 weeks of conservative treatment before approval and enrollment in osteoporosis programs. Sacroplasty is now classified as investigational for all indications. The policy establishes clear contraindications and limits coverage to specific spine levels (T5-L5) with maximum 2 levels per date of service.
High impact
Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty 6.01.17
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield updated its vertebroplasty/kyphoplasty and sacroplasty policy (6.01.17) effective October 15, 2025, with stricter medical necessity criteria requiring prior authorization, comprehensive documentation of failed conservative treatment (4+ weeks), and limiting coverage to T5-L5 spine at maximum 2 levels per date of service. Sacroplasty is now classified as investigational for all indications, and percutaneous vertebroplasty will NOT be separately reimbursed when combined with open spine procedures.
High impact
Osteochondral Grafting of the Knee - (Effective Date - 2026-10-15) 7.01.59
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has established strict medical necessity criteria for osteochondral grafting (OATS/mosaicplasty) of the knee, effective October 15, 2026. Coverage requires patients to meet 10 specific criteria including BMI <35, age ≤49 years, Kellgren-Lawrence Grade II or less, specific defect sizes, failed conservative management for 3+ months, and stable knee anatomy. Hybrid ACI/OATS procedures are deemed investigational and not covered.
High impact
Osteochondral Grafting of the Knee 7.01.59
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield established a new medical policy (effective October 15, 2025) establishing strict coverage criteria for osteochondral grafting procedures of the knee. The policy defines when OATS/mosaicplasty/allograft transplantation is medically appropriate, requiring meeting ALL criteria including BMI <35, age ≤49, specific imaging findings, defect size limits, and 3+ months of failed conservative management. Any procedures outside these criteria or using hybrid ACI/OATS techniques are considered investigational and non-covered.
High impact
Metal-on-Metal Total Hip Resurfacing 7.01.74
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield has issued a new medical policy (7.01.74, effective October 15, 2025) establishing specific coverage criteria for metal-on-metal total hip resurfacing. The procedure is now covered only for patients age 64 or younger who meet strict imaging, symptom, and conservative treatment failure requirements. Claims not meeting ALL criteria will be denied as not medically necessary.
High impact
Metal-on-Metal Total Hip Resurfacing - (Effective Date - 2026-10-15) 7.01.74
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has issued a new medical policy (7.01.74, effective October 15, 2026) establishing coverage criteria for metal-on-metal total hip resurfacing in patients age 64 and younger. The policy requires strict documentation of medical necessity, including imaging findings, function-limiting symptoms lasting 3+ months, failed conservative management, and excludes patients with specific contraindications (metal sensitivity, childbearing potential, dialysis patients, >50% femoral head involvement, and others). Billing teams must implement prior authorization requirements and documentation validation before claims submission.
Medium impact
Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD) 7.01.89
Excellus BlueCross BlueShield·Effective Apr 17, 2025
Excellus BlueCross BlueShield has established a new coverage policy for Magnetic Sphincter Augmentation (LINX device) for GERD treatment, effective April 17, 2025. The policy is considered medically appropriate when strict clinical criteria are met, including age 18+, documented chronic GERD inadequately controlled by PPIs for 6+ months, physician training requirements, and multiple contraindications must be absent. Billing teams must implement prior authorization requirements and ensure providers meet all documented eligibility criteria before claim submission.
Medium impact
Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD) - (Effective Date - 2026-10-15) 7.01.89
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has established coverage criteria for Magnetic Sphincter Augmentation (LINX system) for GERD treatment effective October 15, 2026. MSA is now considered medically appropriate when specific clinical criteria are met, including age 18+, BMI <35, documented pathologic acid exposure, failure of 6+ months of optimized PPI therapy, and absence of contraindications. All other uses remain investigational.
High impact
Magnetic Resonance Imaging (MRI) of the Prostate 6.01.46
Excellus BlueCross BlueShield·Effective May 15, 2026
Excellus BlueCross BlueShield has released a comprehensive new policy (6.01.46, effective May 15, 2026) establishing detailed medical necessity criteria for prostate MRI across five clinical scenarios: suspected prostate cancer, initial work-up/staging, restaging/recurrence, and active surveillance follow-up. The policy introduces specific age, PSA, risk stratification, and clinical history requirements that must be met for coverage. Notably, serial MRIs for monitoring elevated PSA alone are NOT medically necessary, and MR guidance for needle placement is not covered.
High impact
Magnetic Resonance Imaging (MRI) of the Prostate - (Effective Date - 2026-10-15) 6.01.46
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has issued a comprehensive new medical policy (6.01.46) effective October 15, 2026, establishing detailed coverage criteria for prostate MRI across five clinical scenarios: suspected prostate cancer, initial workup/staging, restaging/recurrence, and active surveillance follow-up. The policy specifies strict age and PSA thresholds, risk stratification requirements, and explicitly states that serial MRIs for PSA monitoring alone and MR guidance for needle placement are NOT medically necessary. Billing teams must implement prior authorization requirements based on these specific clinical criteria to avoid claim denials.
High impact
Lysis of Epidural Adhesions 7.01.73
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield has classified lysis of epidural adhesions (epidural adhesiolysis) as investigational, effective October 15, 2025. This means the procedure—performed via catheter-based or endoscopic techniques for back pain treatment—is not covered for reimbursement. Billing teams must deny or reject claims for this procedure and communicate non-coverage to providers.
High impact
Lysis of Epidural Adhesions - (Effective Date - 2026-10-15) 7.01.73
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has classified lysis of epidural adhesions (Racz procedure) as investigational/experimental, effective October 15, 2026. Billing codes 62263, 62264, and 62280 are marked as experimental/investigational (E/I), meaning claims for these procedures will require prior authorization and face coverage denials unless medical necessity criteria are met. Practices must immediately update billing systems to flag these codes and obtain pre-authorization before performing the procedure.
High impact
Lumbar Microdiscectomy 7.01.98
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield implemented a new lumbar microdiscectomy policy (7.01.98) effective October 15, 2025, establishing strict medical necessity criteria for initial and repeat procedures. The policy requires documented failure of at least 2 conservative treatments (6+ weeks each), objective physical exam findings concordant with imaging, and excludes procedures for annular tears, discography alone, or degenerative disc disease. Laser-assisted and percutaneous discectomy techniques, along with annular repair devices, are not medically necessary.
High impact
Lumbar Microdiscectomy - (Effective Date - 2026-10-15) 7.01.98
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has updated its lumbar microdiscectomy policy (7.01.98) effective October 15, 2026, establishing new medical necessity criteria for initial and repeat procedures. The policy requires documented failure of conservative treatment (at least 2 of 3 modalities for 6 weeks each), imaging confirmation of neural compression concordant with symptoms, and absence of unmanaged mental/behavioral health disorders. Laser-assisted techniques, percutaneous discectomy, annular repair devices, and procedures based solely on annular tears, discography, or degenerative disc disease are now explicitly not covered.
High impact
Lumbar Fusion 7.01.117
Excellus BlueCross BlueShield·Effective Mar 1, 2026
Excellus BlueCross BlueShield has updated the Lumbar Fusion policy (07.01.117) effective March 1, 2026, establishing comprehensive medical necessity criteria across six indications with decompression and two without decompression. A critical new requirement mandates documentation of nicotine-free status (never smoker OR cotinine <10ng/mL within 6 weeks) for ALL lumbar fusion cases, which will significantly impact pre-authorization and claim adjudication workflows.
High impact
Lumbar Fusion - (Effective Date - 2026-10-15) 7.01.117
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield issued a comprehensive new lumbar fusion medical policy (7.01.117, effective October 15, 2026) establishing medical necessity criteria for lumbar fusion with and without decompression. The policy introduces strict nicotine-free status requirements (validated by objective cotinine testing within 6 weeks pre-op) as a mandatory criterion across ALL fusion indications, plus detailed imaging and clinical criteria for various fusion scenarios including degenerative spondylolisthesis, instability, spinal deformity, disc herniation, and recurrent disc herniation.
High impact
Lumbar Decompression 7.01.113
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield issued a comprehensive new lumbar decompression policy (effective October 15, 2025) establishing strict medical necessity criteria for primary and repeat decompression procedures, interlaminar device use, and investigational implants. The policy requires prior authorization with detailed documentation of failed conservative treatment (at least 2 modalities for 6 weeks each), imaging concordance, and absence of unmanaged mental health disorders. Procedures not meeting criteria or using prohibited devices will be denied.
High impact
Lumbar Decompression - (Effective Date - 2026-10-15) 7.01.113
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield implemented a new lumbar decompression medical policy (7.01.113, effective Oct 15, 2026) establishing specific clinical criteria for coverage of primary and repeat lumbar decompression procedures, interlaminar decompression devices (Coflex), and lumbar corpectomy. The policy defines strict documentation requirements for prior authorization including failed conservative treatment trials (minimum 2 of 3 options for 6 weeks each), imaging concordance with symptoms, and exclusion of certain diagnoses (annular tears, discography, degenerative disc disease alone) and implant scenarios.
High impact
Intradiscal Procedures 7.01.112
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield has designated a comprehensive list of intradiscal procedures as investigational and non-covered, effective October 15, 2025. This includes thermal techniques (IDET, nucleoplasty, radiofrequency annuloplasty), intradiscal injections (PRP, stem cells, ozone, etc.), and decompression procedures. Billing teams must immediately deny or request prior authorization denial for all claims involving these procedures and update internal systems to reflect non-coverage status.
High impact
Intradiscal Procedures - (Effective Date - 2026-10-15) 7.01.112
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has classified a comprehensive list of intradiscal procedures as investigational/not covered, effective October 15, 2026. This includes thermal techniques (IDET, nucleoplasty, biacuplasty), automated discectomy, endoscopic approaches, and intradiscal injections (PRP, stem cells, ozone, etc.). Billing teams must deny all claims for these procedures and update authorization workflows to reflect non-coverage.
High impact
Home Non-Invasive Positive Pressure Ventilation (NIPPV) Devices for Respiratory Insufficiency and Failure - (Effective Date - 2026-10-15) 1.01.57
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield issued a new comprehensive policy (1.01.57) effective October 15, 2026, establishing medical necessity criteria for home non-invasive positive pressure ventilation (NIPPV) devices across multiple respiratory conditions. The policy details specific clinical and diagnostic thresholds for BPAP devices (with/without backup rates), non-invasive home mechanical ventilators, and multi-function ventilators for neuromuscular disorders, thoracic restrictive disease, hypoventilation syndrome, COPD-related chronic respiratory failure, and obstructive sleep apnea.
High impact
Hip Arthroplasty 7.01.96
Excellus BlueCross BlueShield·Effective Feb 16, 2026
Excellus BlueCross BlueShield updated its Hip Arthroplasty policy (7.01.96) effective February 16, 2026, establishing new medical necessity criteria for partial hip replacement, total hip replacement, and revision procedures. The policy introduces specific imaging requirements (Tönnis Grade 2-3 for osteoarthritis), mandates 3 months of function-limiting pain documentation and failed conservative management, includes exception clauses when non-surgical management is inappropriate, and excludes patients on dialysis from total hip replacement coverage. Billing teams must immediately verify patient eligibility against these criteria before claim submission to avoid denials.

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Archive by year

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Positron Emission Tomography (PET) - Non-Oncologic Applications 6.01.07

Positron Emission Tomography (PET) - Non-Oncologic Applications - (Effective Date - 2026-10-15) 6.01.07

Positive Airway Pressure Devices CPAP BiPAP APAP and Noninvasive Positive Pressure Ventilators (NIV) 1.01.06

Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty - (Effective Date - 2026-10-15) 6.01.17

Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty 6.01.17

Osteochondral Grafting of the Knee - (Effective Date - 2026-10-15) 7.01.59

Osteochondral Grafting of the Knee 7.01.59

Metal-on-Metal Total Hip Resurfacing 7.01.74

Metal-on-Metal Total Hip Resurfacing - (Effective Date - 2026-10-15) 7.01.74

Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD) 7.01.89

Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD) - (Effective Date - 2026-10-15) 7.01.89

Magnetic Resonance Imaging (MRI) of the Prostate 6.01.46

Magnetic Resonance Imaging (MRI) of the Prostate - (Effective Date - 2026-10-15) 6.01.46

Lysis of Epidural Adhesions 7.01.73

Lysis of Epidural Adhesions - (Effective Date - 2026-10-15) 7.01.73

Lumbar Microdiscectomy 7.01.98

Lumbar Microdiscectomy - (Effective Date - 2026-10-15) 7.01.98

Lumbar Fusion 7.01.117

Lumbar Fusion - (Effective Date - 2026-10-15) 7.01.117

Lumbar Decompression 7.01.113

Lumbar Decompression - (Effective Date - 2026-10-15) 7.01.113

Intradiscal Procedures 7.01.112

Intradiscal Procedures - (Effective Date - 2026-10-15) 7.01.112

Home Non-Invasive Positive Pressure Ventilation (NIPPV) Devices for Respiratory Insufficiency and Failure - (Effective Date - 2026-10-15) 1.01.57

Hip Arthroplasty 7.01.96