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43281

PAYER POLICY CHANGES

43281 Insurance Policy Changes

CPT 43281, in plain terms, covers A minimally invasive surgery to fix a hernia that forms beside the esophagus using a small camera. CPT 43281 is referenced in 10 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 43281 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Official descriptor: CPT 43281 on AAPC

Premera Blue Cross · Effective Feb 6, 2026High impact
Medical Policy and Coding Updates - November 2025
Premera HMO plans in Washington have changes from the November 2025 medical policy and coding update. Fifty Routine Test Management policies for laboratory services are effective February 6, 2026, and the notice says they are managed through claims edits for rule-based criteria and are not prior authorization. Other dated items include new medical necessity and prior authorization review for several coded services and Federal Employee Program prior authorization for certain drugs, all listed with an effective date of February 6, 2026.
Providence Health Plan · Effective Jan 1, 2026High impact
Special Alert November 2025 - 2026 Outpatient Site of Service
Effective 1/1/2026, Providence Health Plan (Commercial Fully Insured only) will require prior authorization to review medical necessity for hospital outpatient site of service (place of service 22) for hernia repair and laparoscopic cholecystectomy procedures. Providers must perform these procedures at an ambulatory surgery center (ASC) unless medical necessity criteria are met; the 3-hour prolonged surgery criterion is being removed. Providers without geographically accessible ASC availability must submit attestation to avoid prior authorization delays.
Providence Health Plan · Effective Jan 1, 2026High impact
Special Alert November 2025 - 2026 Outpatient Site of Service
Effective 1/1/2026, Providence Health Plan (Commercial Fully Insured only) now requires prior authorization for hernia repair and laparoscopic cholecystectomy procedures performed at hospital outpatient departments (place of service 22). Services must be performed at an ASC unless medical necessity criteria are met; the 3-hour surgery duration criterion has been removed as a valid reason for hospital outpatient use. Providers without accessible ASC privileges must file attestation to avoid claim denials.
Health Net · Effective Dec 1, 2025High impact
25-998 Streamlining Prior Authorization: Simplifying Processes for Better Efficiency
Health Net California is updating prior authorization requirements effective December 1, 2025, removing PA requirements for some services while adding requirements for others. Key changes include removing PA requirements for ABA therapy, physical therapy, and genetic testing while maintaining PA requirements for TMS, certain surgeries, and specific pharmaceuticals.
Premera Blue Cross · Identified Jun 16, 2026High impact
Medical Policy and Coding Updates - December 2025
With effective dates from December 1, 2025 through March 4, 2026. The update adds medical necessity and prior authorization review for electrophysiology studies, endovascular stent grafts for abdominal aortic aneurysms, shoulder arthrotomy, gastroesophageal reflux surgery, negative pressure wound therapy devices, and hip, knee and spine surgeries for Standard and Basic Federal Employee Program plans effective January 1, 2026. Several codes were made non-covered or investigational, including the services listed under policy 10.01.517 and transcatheter tricuspid valve procedures.
Premera Blue Cross · Identified Jun 16, 2026High impact
Medical Policy and Coding Updates - January 2026
With effective dates from January 1, 2026 through April 8, 2026. The update adds medical necessity and prior authorization review for electrophysiology studies, endovascular stent grafts for abdominal aortic aneurysms, shoulder arthrotomy, shoulder arthroscopy, abdominal wall hernia repair, and hip, knee and spine surgeries for Standard and Basic Federal Employee Program plans, and it expands site of service ASC review to upper GI endoscopy and shoulder procedures. It also changes many drug criteria, including preferred product and quantity limit updates, adds Carelon review for advanced imaging, and lists codes that became non-covered, investigational or terminated.
Premera Blue Cross · Identified Jun 16, 2026High impact
Medical Policy and Coding Updates - February 2026
With effective dates from February 1, 2026 through April 8, 2026. The update adds medical necessity and prior authorization review for mobile cardiac telemetry and implantable loop recorders, electrophysiology studies, endovascular stent grafts for abdominal aortic aneurysms, shoulder arthrotomy, shoulder arthroscopy, gastroesophageal reflux surgery, and abdominal wall hernia repair for federal plans effective April 8, 2026. It also changes many drug criteria, including preferred product, step therapy and quantity limit updates, and adds 50 routine test management policies that support claims editing for laboratory services.
Regence BlueShield · Effective Apr 1, 2026Medium impact
Gastroesophageal Reflux Surgery
Initial esophagogastric fundoplication for symptomatic gastroesophageal reflux disease may be considered medically necessary when no paraesophageal hiatal hernia repair is requested or documented, symptoms are unresponsive to lifestyle modifications, a medication requirement is met (a 4-month total trial of proton pump inhibitors that is ineffective, contraindicated or not tolerated, or PPIs used for 12 or more consecutive months within the past 18 months with surgery considered an alternative to long-term medication), and reflux is objectively confirmed by endoscopy or, if endoscopy is normal, by 24-hour ambulatory esophageal pH monitoring or barium swallow. Fundoplication may also be considered medically necessary for children and adolescents age 17 or younger, for individuals with pulmonary fibrosis and symptomatic or asymptomatic reflux, for a confirmed paraesophageal hiatal hernia (Types II-IV), for esophageal myotomy in achalasia, and for repeat fundoplication after a documented mechanical failure. Gastrectomy, gastrojejunostomy as a stand-alone treatment, and hiatal hernia repair without fundoplication are considered investigational for gastroesophageal reflux.
Aetna · Identified Oct 6, 2026Medium impact
Lung Transplantation (CPB 0598, reviewed 2026-09-08)
Aetna considers lung transplantation medically necessary for qualifying conditions including cystic fibrosis, emphysema and alpha-1-antitrypsin deficiency, Eisenmenger's complex, primary pulmonary hypertension, pulmonary fibrosis, sarcoidosis, lymphangioleiomyomatosis with end-stage pulmonary disease, bronchopulmonary dysplasia, and graft-versus-host disease or failed primary lung graft, when the member meets the transplanting institution's selection criteria or, without those criteria, the general and disease-specific criteria in the policy. Cystic fibrosis requires at least 2 listed signs of clinical deterioration, such as decreasing FEV1, FEV1 less than 30% predicted, or recurrent massive hemoptysis, and emphysema requires both hospitalization for COPD exacerbation with hypercapnia in the preceding year and a BODE index of 7 or above. Lung transplantation is considered not medically necessary for malignancy involving the lung, multi-system disease, refractory uncontrolled hypertension, other effective treatments being available, and smoking without 6 months of abstinence.
Aetna · Identified Aug 19, 2026Medium impact
Lung Transplantation (CPB 0598, reviewed 2025-12-02)
Aetna considers lung transplantation medically necessary for qualifying conditions, including cystic fibrosis, emphysema including alpha-1-antitrypsin deficiency, pulmonary fibrosis, pulmonary hypertension, Eisenmenger's complex, sarcoidosis, lymphangioleiomyomatosis, bronchopulmonary dysplasia and graft-versus-host disease, for members who meet the transplanting institution's selection criteria or, where there are none, the general and disease-specific selection criteria. Lung transplantation is considered not medically necessary for contraindications including lung malignancy, multi-system disease, acute or chronic active infection not adequately treated, and smoking, since members with a history of smoking must be abstinent for 6 months before being considered eligible. Lobar lung transplantation, anti-thymocyte globulin for acute cellular rejection and ex vivo lung perfusion for preservation and transplant of donor lungs are considered medically necessary, while AlloSure, Prospera Lung and lung xenotransplantation are considered experimental, investigational or unproven.

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REFERENCE DATA

Payers with rules7

Payers requiring prior auth7

Anthem BCBS · Effective November 1, 2026
Prior authorization required
Anthem Local PPO Precertification/Prior Authorization List (California | Anthem Blue Cross | Commercial)
Fidelis Care · Effective November 1, 2026
Prior authorization required in some cases
Fidelis Care Metal-Level Products authorization grid
BCBS Arizona · Effective October 1, 2026
Prior authorization required
AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Updated 10/01/2026)

FREQUENTLY ASKED QUESTIONS

Does Ambetter require prior authorization for 43281?

Ambetter lists 43281 on Ambetter from Arizona Complete Health CMS-0057-F prior authorization requirements for exchange plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Anthem BCBS require prior authorization for 43281?

Anthem BCBS lists 43281 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 BCBS Arizona require prior authorization for 43281?

BCBS Arizona lists 43281 on AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Updated 10/01/2026) for medicare advantage plans (list dated October 1, 2026). Verify with the payer before scheduling.

Does BCBS Illinois require prior authorization for 43281?

BCBS Illinois lists 43281 on 2026 Commercial Outpatient Medical Surgical Prior Authorization Codes for commercial plans, with conditions (list dated January 1, 2026). Verify with the payer before scheduling.

Does CalViva Health require prior authorization for 43281?

CalViva Health lists 43281 on CalViva Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

What insurance policy changes affect CPT 43281?

There are 10 tracked policy changes affecting CPT 43281, including updates from Premera Blue Cross, Providence Health Plan, Health Net. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 43281?

Payers that have issued tracked updates for CPT 43281 include: Premera Blue Cross, Providence Health Plan, Health Net, Regence BlueShield, Aetna.

How do I get notified when CPT 43281 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 43281. 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 43281?

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 43281 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 2025

Special Alert November 2025 - 2026 Outpatient Site of Service

Special Alert November 2025 - 2026 Outpatient Site of Service

25-998 Streamlining Prior Authorization: Simplifying Processes for Better Efficiency

Medical Policy and Coding Updates - December 2025

Medical Policy and Coding Updates - January 2026

Medical Policy and Coding Updates - February 2026

Gastroesophageal Reflux Surgery

Lung Transplantation (CPB 0598, reviewed 2026-09-08)

Lung Transplantation (CPB 0598, reviewed 2025-12-02)

Prior authorization required

Prior authorization required in some cases