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28291

PAYER POLICY CHANGES

28291 Insurance Policy Changes

CPT 28291, in plain terms, covers Surgery to fix a stiff big toe joint by implanting a device to restore movement and function. CPT 28291 is referenced in 17 tracked payer policy changes from Premera Blue Cross, Providence Health Plan, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 28291 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Official descriptor: CPT 28291 on AAPC

Premera Blue Cross · Effective Nov 1, 2026High impact
Medical Policy and Coding Updates - November 2026
Premera Blue Cross (WA) published its November 2026 medical policy and coding update. Several changes take effect on different dates: Nov 1, Nov 6, Nov 15, Nov 16, 2026, Dec 3, 2026, Jan 1, 2027, and Feb 5, 2027, including new prior authorization/medical necessity review requirements for specific CPT/HCPCS codes (e.g., 33340, 31240, J1818, J9999, 52284, 17313–17315, 30117, 31242, 31243, S3600, S3601, C9762, C9763) and some codes now considered investigational or non-covered. Because the notice mixes past, current and future effective dates, the billing team should confirm applicability per date and per plan before acting.
Providence Health Plan · Effective May 11, 2026High impact
Special Alert March 2026 - Outpatient Surgical Site of Service Notice
Effective 2026-05-11, Providence Health Plan will add medical necessity review for hospital outpatient site of service (place of service 22) for knee arthroscopy, shoulder arthroscopy, and small joint surgery procedures on commercial fully insured groups. If medical policy criteria are not met for outpatient hospital setting, services must be performed at an ASC for coverage. Providers without geographically accessible ASC must file attestation or note unavailability on prior authorization requests.
Providence Health Plan · Effective May 11, 2026High impact
Special Alert May 2026 UPDATE - Outpatient Surgical Site of Service Notice
Effective 2026-05-11, Providence Health Plan (Commercial Fully Insured Groups only) now requires medical necessity review for hospital outpatient sites of service (place of service 22) for knee arthroscopy, shoulder arthroscopy, and small joint surgery procedures. If medical policy criteria are not met for outpatient hospital setting, services must be performed at an ASC for coverage. Providers without geographically accessible ASCs must file attestation or note unavailability on prior authorization requests.
Providence Health Plan · Effective May 11, 2026High impact
Special Alert May 2026 UPDATE - Outpatient Surgical Site of Service Notice
Effective May 11, 2026, Providence Health Plan will now review medical necessity for hospital outpatient site of service (place of service 22) for knee arthroscopy, shoulder arthroscopy, and small joint surgery procedures on commercial fully insured groups. If medical policy criteria are not met for outpatient hospital setting, procedures must be performed at an ASC for coverage. Prior authorization requirements remain in place, with the addition of site-of-service medical necessity review.
Providence Health Plan · Effective May 11, 2026High impact
Special Alert March 2026 - Outpatient Surgical Site of Service Notice
Effective May 11, 2026, Providence Health Plan will add medical necessity review for hospital outpatient site of service (place of service 22) for knee arthroscopy, shoulder arthroscopy, and small joint surgery procedures on commercial fully insured groups. If medical necessity criteria are not met for outpatient hospital setting, the procedure must be performed at an ASC for coverage. Prior authorization requirements remain unchanged for the procedures themselves, but now include site-of-service review.
Premera Blue Cross · Identified Nov 1, 2026High impact
Medical Policy and Coding Updates - November 2026
Premera's November 2026 Medical Policy and Coding Updates notice lists new, revised, deleted and renumbered medical policies, pharmacy policies and coding changes, with dates from November 1, 2026 through February 5, 2027. Several coding updates list codes that now require review for medical necessity and prior authorization, or are now considered investigational or non-covered. The notice also describes Carelon radiation oncology and genetic testing guideline updates effective November 15, 2026.
Premera Blue Cross · Identified Oct 1, 2026High impact
Medical Policy and Coding Updates - October 2026
Premera's October 2026 medical policy update covers new, revised and deleted medical policies, pharmacy policies, and coding changes with effective dates from October 1, 2026 through January 1, 2027. Several policies now require medical necessity review and prior authorization, including Denosumab Products (5.01.658), Miscellaneous Oncology Drugs (5.01.540) and ALK Tyrosine Kinase Inhibitors (5.01.638), and Bioengineered Skin and Soft Tissue Substitutes (7.01.582) and Laboratory Testing Investigational Services (2.04.520) are now considered investigational. Changes dated October 1, 2026 are already effective, and changes dated November 6, 2026 and later are future changes.
Premera Blue Cross · Identified Sep 3, 2026High impact
Medical Policy and Coding Updates - September 2026
Premera's September 2026 medical policy and coding update adds new review requirements for several services on different dates. Negative pressure wound therapy codes 97605, 97606, 97607 and 97608 now require review for medical necessity and prior authorization effective September 4, 2026, and immune checkpoint inhibitors now require review for medical necessity and prior authorization effective September 1, 2026. Endovascular stent grafts for abdominal aortic aneurysms (codes 34717 and 34718) will require medical necessity and prior authorization review effective November 6, 2026, and Carelon's radiation oncology guideline states radiation therapy is considered not medically necessary for select conditions, including osteoarthritis, neovascular age-related macular degeneration and refractory ventricular tachycardia, for dates of service on and after November 15, 2026.
Premera Blue Cross · Identified Aug 6, 2026High impact
Medical Policy and Coding Updates - August 2026
Premera's August 2026 medical policy and coding update changes coverage review for many services, with effective dates running from August 1 through November 15, 2026. Upper gastrointestinal endoscopy in adults, negative pressure wound therapy, and endovascular stent grafts for abdominal aortic aneurysms now carry added site-of-service, medical necessity or prior authorization review requirements. Carelon guidelines for radiology, sleep disorder management and genetic testing took effect for dates of service on and after September 19, 2026, and the radiation oncology and genetic testing guidelines take effect November 15, 2026.
Regence BlueShield · Effective Nov 1, 2026Medium impact
Surgical Site of Care- Hospital Outpatient
Effective November 1, 2026, site of care medical necessity reviews apply to the listed surgical procedures only when they are performed in an outpatient hospital setting. Use of a hospital outpatient department instead of an ambulatory surgery center or physician office may be considered medically necessary when one or more listed criteria are met, such as no geographically accessible in-network ASC that has the necessary equipment, a procedure that requires discontinuing medications that necessitate inpatient monitoring or treatment, ASA Physical Status III or higher, or a BMI over 40. Hospital outpatient use is considered not medically necessary when the criteria are not met.
Regence BlueShield · Effective Nov 1, 2026Medium impact
Surgical Site of Care - Hospital Outpatient
This surgical site of care policy sets criteria for when a hospital outpatient department may be considered medically necessary instead of an ambulatory surgery center or physician office for listed surgical procedures. Hospital outpatient use may be considered medically necessary when one or more criteria are met, such as no qualifying in-network ASC within 25 miles that can provide the necessary care, an ASA Physical Status Classification of III or higher, a body mass index over 40, or a surgery expected to last longer than 3 hours. Use of a hospital outpatient department instead of an ASC or physician office is considered not medically necessary when the criteria are not met. The procedure may require prior authorization separately under its own medical policy.
Aetna · Identified Aug 17, 2026Medium impact
Metatarsal Phalangeal Joint Replacement (CPB 0708, reviewed 2025-11-24)
Aetna considers hemiarthroplasty and total prosthetic replacement arthroplasty with silastic implants medically necessary for persons with disabling arthritis of the first metatarsal phalangeal joint (hallux rigidus), with the In2Bones Reference Toe System and Primus Flexible Great Toe implants given as examples. Aetna considers the following experimental, investigational or unproven because their effectiveness and durability have not been established: the Accu-Joint Hemi Implant, the bioabsorbable poly-L-D-lactic acid RegJoint inter-positional implant, ceramic prostheses such as the Moje implant, inter-positional arthroplasty with biologic spacers such as the InterPhlex implant, total metallic implants, modular implants such as the Arthrex, Cartiva, METIS, OsteoMed ReFlexion and ToeFit-Plus systems, joint replacement for other indications not listed as covered, and the Roto-Glide implant for avascular necrosis of the MTP joint.
Aetna · Identified Aug 14, 2026Medium impact
Distal Interphalangeal (DIP), Metacarpophalangeal (MCP) and Proximal Interphalangeal (PIP) Joint Implants (CPB 0798, reviewed 2026-02-24)
Aetna considers MCP and PIP joint implants medically necessary for members with symptomatic rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis, or post-traumatic arthritis when conservative medical management fails to relieve pain or digit deformity interferes with hand function and activities of daily living. The listed implants are Ascension MCP and Integra PyroCarbon MCP implants when soft tissue reconstruction can provide adequate stabilization, Ascension PIP and Avanta MCP and PIP implants when soft tissue and bone can provide adequate stabilization and fixation, and silicone-elastomer MCP and PIP total joint implants. Aetna considers the other MCP and PIP implant indications, DIP joint implants and splints, CMC and TMC joint implants, CapFlex-PIP, Tactys, Silktoe, PIP resurfacing arthroplasty, and X-Fuse for DIP joint arthrodesis experimental, investigational, or unproven.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Synthetic Cartilage Implants for Joint Pain
Synthetic cartilage implants are considered investigational for the treatment of articular cartilage damage. The Cartiva synthetic polyvinyl alcohol implant was FDA-approved in 2016 for painful degenerative or posttraumatic arthritis in the first metatarsophalangeal joint, and the policy states that the Federal Employee Program may dictate that FDA-approved devices are not considered investigational and may be assessed only on the basis of medical necessity. The 09/11/2025 review made no changes to the policy statement.
Premera Blue Cross · Identified Jun 18, 2026Medium impact
Medical Policy and Coding Updates - August 2019
Effective August 1, 2019, handheld radiofrequency spectroscopy code 0546T now requires review for investigational status, and functional electrical stimulation code E0770 now requires review for investigational status and no longer requires prior authorization. Effective August 2, 2019, denosumab code J0897 now requires review for medical necessity and prior authorization, and synthetic cartilage implant codes 28291, L8641 and L8642 now require review for investigational status and prior authorization. Transcatheter mitral valve repair codes 0483T and 0484T no longer require review for medical necessity or prior authorization, and genetic testing codes G0452 and S3620 are no longer reviewed for medical necessity.
Premera Blue Cross · Identified Jun 16, 2026Medium impact
Medical Policy and Coding Updates - October 2024
Effective January 3, 2025, Premera HMO medical necessity criteria for Dupixent (dupilumab) in moderate to severe asthma were updated, requiring two or more asthma exacerbations in the previous 12 months requiring oral corticosteroids, or one or more exacerbations requiring hospitalization, an emergency department visit, or an urgent care visit, or forced expiratory volume in 1 second of less than 80% predicted, with a blood eosinophil count greater than 300 cells/mcL. The same effective date added Humira (adalimumab) criteria for psoriatic arthritis, Crohn's disease, ulcerative colitis, uveitis, sarcoidosis and pyoderma gangrenosum, moved Inflectra (infliximab-dyyb) to a first-line TNF-alpha antagonist option for several indications, and removed Hyrimoz (adalimumab-adaz) from first-line options. A new Shoulder Arthroplasty policy (7.01.590) with medical necessity criteria for total, reverse, hemi, and revision shoulder arthroplasty is also listed under the January 3, 2025 effective date, and Restasis (cyclosporine ophthalmic emulsion) was added for dry eye disease in individuals aged 18 years and older effective October 1, 2024.
Aetna · Identified Nov 2, 2026Low impact
Distal Interphalangeal (DIP), Metacarpophalangeal (MCP) and Proximal Interphalangeal (PIP) Joint Implants (CPB 0798, reviewed 2026-10-30)
Aetna reviewed its clinical policy bulletin on finger and thumb joint implants (CPB 0798) on 10/30/2026. The bulletin says Aetna covers certain MCP and PIP joint implants for symptomatic rheumatoid arthritis, lupus, osteoarthritis or post-traumatic arthritis when conservative care has failed, and it calls DIP, CMC/TMC, CapFlex-PIP, Tactys, X-Fuse, Duafit, Silktoe and PIP resurfacing implants experimental, investigational or unproven. The source does not say what changed from the prior version and gives no new effective date.

Watch 28291

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REFERENCE DATA

Payers with rules8

Payers requiring prior auth8

Anthem BCBS · Effective November 1, 2026
Prior authorization required
Anthem Local PPO Precertification/Prior Authorization List (California | Anthem Blue Cross | Commercial)
Cigna · Effective March 7, 2026
Prior authorization required
Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs (EviCore)
CalViva Health · Effective December 31, 2025
Prior authorization required
CalViva Health CMS-0057-F prior authorization requirements

FREQUENTLY ASKED QUESTIONS

Does AmeriHealth Caritas require prior authorization for 28291?

AmeriHealth Caritas lists 28291 on AmeriHealth Caritas Louisiana prior authorization service list for medicaid managed plans. Verify with the payer before scheduling.

Does Anthem BCBS require prior authorization for 28291?

Anthem BCBS lists 28291 on Anthem Local PPO Precertification/Prior Authorization List (California | Anthem Blue Cross | Commercial) for commercial plans (list dated November 1, 2026). Verify with the payer before scheduling.

Does CalViva Health require prior authorization for 28291?

CalViva Health lists 28291 on CalViva Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Capital Blue Cross require prior authorization for 28291?

Capital Blue Cross lists 28291 on Capital Blue Cross single source preauthorization code list for commercial plans. Verify with the payer before scheduling.

Does Cigna require prior authorization for 28291?

Cigna lists 28291 on Cigna Master Precertification List for commercial plans (list dated October 1, 2026). Verify with the payer before scheduling.

What insurance policy changes affect CPT 28291?

There are 17 tracked policy changes affecting CPT 28291, including updates from Premera Blue Cross, Providence Health Plan, Regence BlueShield. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 28291?

Payers that have issued tracked updates for CPT 28291 include: Premera Blue Cross, Providence Health Plan, Regence BlueShield, Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when CPT 28291 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 28291. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for CPT 28291?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

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Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 28291 in one place.

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All billing codes J3590 C9399 J3490 99215 99213 99202

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Medical Policy and Coding Updates - November 2026

Special Alert March 2026 - Outpatient Surgical Site of Service Notice

Special Alert May 2026 UPDATE - Outpatient Surgical Site of Service Notice

Special Alert May 2026 UPDATE - Outpatient Surgical Site of Service Notice

Special Alert March 2026 - Outpatient Surgical Site of Service Notice

Medical Policy and Coding Updates - November 2026

Medical Policy and Coding Updates - October 2026

Medical Policy and Coding Updates - September 2026

Medical Policy and Coding Updates - August 2026

Surgical Site of Care- Hospital Outpatient

Surgical Site of Care - Hospital Outpatient

Metatarsal Phalangeal Joint Replacement (CPB 0708, reviewed 2025-11-24)

Distal Interphalangeal (DIP), Metacarpophalangeal (MCP) and Proximal Interphalangeal (PIP) Joint Implants (CPB 0798, reviewed 2026-02-24)

Synthetic Cartilage Implants for Joint Pain

Medical Policy and Coding Updates - August 2019

Medical Policy and Coding Updates - October 2024

Distal Interphalangeal (DIP), Metacarpophalangeal (MCP) and Proximal Interphalangeal (PIP) Joint Implants (CPB 0798, reviewed 2026-10-30)

Prior authorization required

Prior authorization required

Prior authorization required

Does AmeriHealth Caritas require prior authorization for 28291?

Does Anthem BCBS require prior authorization for 28291?

Does CalViva Health require prior authorization for 28291?

Does Capital Blue Cross require prior authorization for 28291?

Does Cigna require prior authorization for 28291?

What insurance policy changes affect CPT 28291?

Which payers have updated policy for CPT 28291?

How do I get notified when CPT 28291 policy changes?

Why do payers change policies for CPT 28291?