All Insurance Policy Changes (Page 96)

Continuing from page 95. 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
Hip Arthroplasty - (Effective Date - 2026-10-15) 7.01.96
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has issued a new Hip Arthroplasty medical policy (7.01.96) effective October 15, 2026, establishing coverage criteria for partial hip replacement, total hip replacement, and revision procedures. The policy defines specific imaging findings, symptom requirements, and non-surgical management prerequisites that must be met for procedures to be considered medically necessary. Key exclusions include active infections, vascular insufficiency, dialysis patients, and inflammatory arthritis affecting both femoral head and acetabulum.
High impact
Facet Joint Injections/ Medial Branch Blocks 7.01.116
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield implemented a comprehensive new policy (effective Oct 15, 2025) establishing strict criteria for facet joint injections and medial branch blocks, including diagnostic requirements (3+ months pain, 4+ weeks conservative treatment), imaging studies to rule out other causes, limits of 3 levels per session, and prohibition of certain injectates (biologics) and guidance methods (ultrasound). Therapeutic injections are now only reimbursable as alternatives when radiofrequency ablation is contraindicated, and all procedures must use fluoroscopic or CT guidance.
High impact
Facet Joint Injections/ Medial Branch Blocks - (Effective Date - 2026-10-15) 7.01.116
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield released a comprehensive new policy (7.01.116) effective October 15, 2026, establishing strict medical necessity criteria for facet joint injections and medial branch blocks. The policy requires documented conservative treatment failure, imaging correlation, fluoroscopic/CT guidance, limits procedures to 3 contiguous levels, restricts diagnostic injections to 2 per level, and requires positive response confirmation before therapeutic treatment. Billing teams must immediately implement prior authorization workflows to enforce these requirements.
Medium impact
Epidural Steroid Injections 7.01.115
Excellus BlueCross BlueShield·Identified Jul 16, 2026
Failed to analyze policy change
Medium impact
Epidural Steroid Injections - (Effective Date - 2026-10-15) 7.01.115
Excellus BlueCross BlueShield·Identified Jul 16, 2026
Failed to analyze policy change
High impact
Continuous Positive Airway Pressure (CPAP) and Auto-Adjusting Positive Airway Pressure (APAP) Devices - (Effective Date - 2026-10-15) 1.01.06
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield updated its CPAP/APAP device policy (effective Oct 15, 2026) with stricter medical necessity criteria for initial 90-day trials, new compliance requirements (70% usage over 4+ hours/night for 30 days), and clarified non-coverage for snoring-only cases, cleaning devices (SoClean), and cosmetic replacements. Billing teams must enforce these criteria for claim submission and prior authorization decisions.
High impact
Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (CCTA) 6.01.34
Excellus BlueCross BlueShield·Effective May 15, 2026
Excellus BlueCross BlueShield has issued a comprehensive new policy (6.01.34) effective May 15, 2026, establishing detailed medical necessity criteria for Cardiac Computed Tomography (CCT) and Coronary Computed Tomographic Angiography (CCTA) procedures. The policy expands covered indications across multiple cardiac scenarios including chest pain evaluation, anomalous coronary artery assessment, pre-transplant evaluation, and structural heart disease assessment, while also establishing new requirements for FFR-CT and coronary plaque quantification.
High impact
Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (CCTA) - (Effective Date - 2026-10-15) 6.01.34
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield issued a comprehensive new policy (6.01.34, effective October 15, 2026) establishing medical necessity criteria for Cardiac Computed Tomography (CCT) and Coronary Computed Tomographic Angiography (CCTA) procedures. The policy specifies 18 major clinical indications for coverage, introduces FFR-CT noninvasive assessment guidelines, and establishes criteria for coronary CTA plaque quantification. Billing teams must implement these criteria into prior authorization and claims review workflows immediately.
High impact
Autologous Chondrocyte Implantation (ACI) - (Effective Date - 2026-10-15) 7.01.38
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has issued a new medical policy (7.01.38, effective October 15, 2026) establishing specific medical necessity criteria for Autologous Chondrocyte Implantation (ACI/MACI) procedures on the knee. The policy defines strict patient eligibility (age 15-55, BMI ≤35), imaging/arthroscopic requirements (Kellgren-Lawrence Grade II or less, full-thickness defects 1-10cm²), and mandates 3+ months of failed conservative treatment. Claims not meeting ALL criteria will be denied. Additionally, Hybrid ACI/OATS procedures are classified as investigational and not covered.
High impact
Autologous Chondrocyte Implantation (ACI) 7.01.38
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield established a new medical policy (7.01.38) effective October 15, 2025, for Autologous Chondrocyte Implantation (ACI) using matrix-induced ACI (MACI) implants for knee cartilage defects. The policy defines strict coverage criteria including BMI ≤35, age 15-55, specific imaging/arthroscopic findings, and failure of conservative management for ≥3 months. Hybrid ACI/OATS procedures are classified as investigational and not covered. This is a brand-new policy requiring immediate billing system updates and prior authorization protocols.
High impact
Artificial Lumbar Intervertebral Disc 7.01.63
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield has implemented a new policy (effective October 15, 2025) establishing strict medical necessity criteria for artificial lumbar intervertebral disc arthroplasty. The policy requires patients to be aged 18-60, undergo 6+ months of conservative treatment without clinically meaningful improvement, meet specific imaging criteria (single-level L3-4, L4-5, or L5-S1 degeneration only), and absence of multiple contraindications including osteoporosis, spondylolisthesis >3mm, spinal stenosis, and autoimmune disorders. Prior authorization is now mandatory with extensive documentation requirements.
High impact
Artificial Lumbar Intervertebral Disc - (Effective Date - 2026-10-15) 7.01.63
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has released a NEW medical policy (effective October 15, 2026) establishing coverage criteria for artificial lumbar intervertebral disc (total disc arthroplasty) procedures. The policy defines strict medical necessity requirements including age limits (18-60), single-level procedures only (L3-4, L4-5, L5-S1), mandatory 6-month conservative treatment trial, and multiple imaging/clinical contraindications. Prior authorization will be required with comprehensive documentation of failed non-surgical management.
High impact
Artificial Cervical Intervertebral Disc 7.01.80
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield established a new medical policy (7.01.80, effective October 15, 2025) for artificial cervical intervertebral disc implants. The policy defines strict criteria for coverage of primary disc replacement for radiculopathy and myelopathy (ages 18-60, single or two-level procedures at C3-C7), plus coverage for adjacent segment disease following prior disc arthroplasty. Prior authorization will be required with extensive documentation of failed conservative treatment and imaging confirmation.
High impact
Artificial Cervical Intervertebral Disc - (Effective Date - 2026-10-15) 7.01.80
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has issued a NEW medical policy (7.01.80) effective October 15, 2026, establishing comprehensive coverage criteria for artificial cervical intervertebral disc implants. The policy covers initial/primary total disc replacements and adjacent segment disease replacements for both radiculopathy and myelopathy when strict medical necessity criteria are met, including failed conservative treatment, imaging confirmation, specific physical exam findings, and absence of cervical instability. Billing teams must implement prior authorization requirements and ensure all supporting documentation is collected before claims submission.
Medium impact
26-819 Complete Your Required SNP Care Training
Health Net·Identified Jul 16, 2026
CMS now requires annual Model of Care training for all providers treating Special Needs Plan (SNP) members, including Dual-Eligible SNP (D-SNP) and Chronic Condition SNP (C-SNP) members. Providers must complete training and submit a voluntary attestation by December 31, 2026. Non-compliance may result in CMS audits and potential credentialing issues.
Low impact
Reminder: August 2026 Medi-Cal In-Person Training Event
Medi-Cal·Effective Aug 11, 2026
Medi-Cal is hosting a free in-person training event on August 11, 2026, in Santa Barbara, CA for providers to learn billing, claims, and eligibility topics. The course catalog has been updated: the 'Navigating the Medi-Cal Website' course has been added while the 'CCS/GHPP' course has been removed. Providers must register by August 10, 2026, at 11:59 p.m. through the Medi-Cal Learning Portal.
Medium impact
[California] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, CPT code 0600U (FidaLab Molecular Wound Infection Test) will require precertification/prior authorization through Carelon Medical Benefits Management for all Anthem Blue Cross Medicare Advantage PPO plans in California. Providers must obtain approval before ordering this genetic/molecular testing.
High impact
[California] Prior authorization and step therapy updates
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Blue Cross Medi-Cal (California Medicaid) is adding four specialty pharmacy drugs to prior authorization requirements and implementing step therapy reviews for multiple pegfilgrastim and filgrastim biosimilars plus nivolumab. All medical claims for these drugs must include NDC codes and will require prior authorization initiation or renewal, with step therapy applied during review.
Medium impact
[New York] Prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, CPT code A9552 (Fluorodeoxyglucose F-18 FDG diagnostic) now requires prior authorization through Carelon Medical Benefits Management for New York Medicaid patients. Billing teams must implement prior authorization checks for this nuclear medicine code before the effective date to avoid claim denials.
Medium impact
[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, CPT code 0600U (FidaLab Molecular Wound Infection Test) now requires precertification/prior authorization through Carelon Medical Benefits Management for Anthem Blue Cross and Blue Shield Medicare Advantage members in New York. Ordering and servicing providers must submit authorization requests via Carelon's provider portal, Availity Essentials, or email before performing this genetic/molecular test.
Medium impact
[Ohio] Precertification/prior authorization requirement changes
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Blue Cross and Blue Shield Medicaid in Ohio is adding a new prior authorization requirement for CPT code 0600U (infectious disease wound infection testing with organism and antibiotic resistance identification). All claims for this test must be precertified before submission to avoid denial.
High impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, four echocardiography CPT codes (93320, 93321, 93325, 93352) now require precertification/prior authorization through Carelon Medical Benefits Management for all Anthem FIDE (Fully Integrated Dual Eligible) plans in Ohio. Billing teams must implement prior auth workflows for these cardiology procedures to avoid claim denials.
Medium impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, CPT code 0600U (FidaLab Molecular Wound Infection Test) now requires precertification/prior authorization through Carelon Medical Benefits Management for Anthem Blue Cross and Blue Shield Medicare Advantage members in Ohio. Ordering and servicing providers must submit prior auth requests via the Carelon provider portal, Availity Essentials, or email before performing this test.
High impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Carelon Medical Benefits Management is adding 13 new CPT and HCPCS codes across sleep medicine, radiation oncology, radiology, and cardiovascular specialties to the precertification/prior authorization requirement for all Ohio FIDE (Fully Integrated Dual Eligible) plans. Providers must obtain prior authorization before delivering these services or face potential claim denials.
Medium impact
[Virginia] Prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, CPT code A9552 (Fluorodeoxyglucose F-18 FDG diagnostic) will require prior authorization through Carelon Medical Benefits Management for Virginia Medicaid (HealthKeepers, Inc. and Anthem HealthKeepers Plus) members. Ordering and servicing providers must submit prior authorization requests via the Carelon provider portal, Availity Essentials, or other designated channels before delivering this service.

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Archive by year

2023 2024 2025 2026

Hip Arthroplasty - (Effective Date - 2026-10-15) 7.01.96

Facet Joint Injections/ Medial Branch Blocks 7.01.116

Facet Joint Injections/ Medial Branch Blocks - (Effective Date - 2026-10-15) 7.01.116

Epidural Steroid Injections 7.01.115

Epidural Steroid Injections - (Effective Date - 2026-10-15) 7.01.115

Continuous Positive Airway Pressure (CPAP) and Auto-Adjusting Positive Airway Pressure (APAP) Devices - (Effective Date - 2026-10-15) 1.01.06

Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (CCTA) 6.01.34

Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (CCTA) - (Effective Date - 2026-10-15) 6.01.34

Autologous Chondrocyte Implantation (ACI) - (Effective Date - 2026-10-15) 7.01.38

Autologous Chondrocyte Implantation (ACI) 7.01.38

Artificial Lumbar Intervertebral Disc 7.01.63

Artificial Lumbar Intervertebral Disc - (Effective Date - 2026-10-15) 7.01.63

Artificial Cervical Intervertebral Disc 7.01.80

Artificial Cervical Intervertebral Disc - (Effective Date - 2026-10-15) 7.01.80

26-819 Complete Your Required SNP Care Training

Reminder: August 2026 Medi-Cal In-Person Training Event

[California] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[California] Prior authorization and step therapy updates

[New York] Prior authorization requirement updates — Carelon Medical Benefits Management

[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[Ohio] Precertification/prior authorization requirement changes

[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[Virginia] Prior authorization requirement updates — Carelon Medical Benefits Management