CPT 83036 is referenced in 14 tracked payer policy changes from Blue Cross Blue Shield of Wyoming, Blue Cross Blue Shield of Vermont, and 6 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 83036 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
This policy clarifies that pharmacy prior authorization submission methods remain unchanged and are policy-dependent across BlueSelect, BlueChoice, and Wyoming Choice plans. Additionally, starting November 20, 2026, Medicare Advantage claims must include specific Category II codes (3048F, 3049F, 3050F, 3044F, 3045F, 3046F, 3051F, or 3052F) when billing CPT codes 80061, 83036, or 83721, or claims will be denied.
Members receive the preventive services listed here at no cost when they align with USPSTF A- and B-rated services, ACIP vaccine recommendations, HRSA infant, child, adolescent and women's preventive guidelines, and Vermont state mandates. Covered procedure and diagnosis codes are listed for screenings, counseling, vaccines and preventive medications for children, adults and pregnant members, and some services require prior approval. Recent revisions add a Pre-Diabetes Preventive Interventions section for adults 18 and older, split mammography into diagnostic, ultrasound and MRI sections, and add pregnancy diagnosis codes effective 12/01/2026.
CareSource Georgia Medicaid will implement enhanced claims editing effective December 4, 2026, adding new validation rules for modifier usage, E/M code bundling, lab tests, surgical pathology units, and DME replacement history. Claims that fail these edits will be denied.
Point32Health consolidated multiple legacy payment policies into new integrated policies effective November 1, 2026, affecting Evaluation and Management, DME/Medical Supplies, Rehabilitation/Long-Term Acute Care, and Skilled Nursing Facility services across Harvard Pilgrim and Tufts Health plans. The payer also removed specific CPT codes from several laboratory policies and clarified modifier usage (PO and PN) for outpatient facility billing.
Arkansas Blue Cross revised coverage criteria for three laboratory testing policies effective 11/01/2026: (1) Nongenetic prenatal screening now covers only specific tests (blood type, Rh status, anemia, Group B strep, rubella, varicella immunity, and fetal fibronectin for preterm labor symptoms) with 40 procedure codes removed; (2) CRP/ESR inflammation testing expanded to cover 17 specific inflammatory conditions with defined frequency; (3) Alpha-1 antitrypsin testing removed 2 codes with no coverage criteria changes. Billing teams must identify and deny claims for removed codes and non-covered indications.
Point32Health issued a metabolic monitoring policy for patients on antipsychotic medications, emphasizing annual screening for diabetes and cholesterol levels. The policy provides approved CPT codes for billing glucose, HbA1c, LDL-C, and other cholesterol tests, and requires providers to document baseline metabolic testing at discharge and coordinate care across behavioral health, primary care, and prescribing providers.
Point32Health issued new guidance requiring annual metabolic monitoring (glucose, HbA1c, and cholesterol testing) for all patients on antipsychotic medications across all age groups. Billing teams must use specific approved CPT codes for these screenings and ensure proper documentation, especially for inpatient psychiatric discharges. This policy emphasizes care coordination among providers and includes a referral pathway for Tufts Health Together SMI members.
BCBS Wyoming now requires Category II codes (3044F, 3051F, 3052F, or 3046F) to be billed alongside CPT 83036 (HbA1c lab tests) based on the test result percentage ranges. Claims without the appropriate Category II code will be denied and require resubmission.
Capital Blue Cross updated HEDIS quality measure requirements for three diabetes-related screenings: eye exams (EED), glycemic status assessment (GSD), and kidney health evaluation (KED). This administrative bulletin clarifies documentation requirements, acceptable test types, and exclusion criteria for diabetic patients aged 18-85.
Metal-on-metal hip resurfacing with an FDA-approved device is considered medically necessary as an alternative to total hip arthroplasty for physically active members under 65 who have advanced hip joint disease from osteoarthritis, avascular necrosis or post-traumatic arthritis and meet the listed criteria. Members should have at least 12 weeks of documented non-surgical treatment, unless contraindicated. Hip resurfacing is considered not medically necessary with contraindications such as active joint infection, metal allergy, morbid obesity (BMI greater than 40) and females of child-bearing age, and shoulder, knee, patellar, wrist, facet joint, toe joint and other listed resurfacing procedures are considered experimental, investigational or unproven.
Aetna's Clinical Policy Bulletin 0743 sets medical necessity criteria for cervical, thoracic and lumbar laminectomy, laminoplasty, spinal fusion, vertebral corpectomy, and removal of spinal instrumentation. Most covered indications require advanced imaging (CT or MRI) showing at least moderate central, lateral recess or foraminal stenosis, or nerve root or spinal cord compression, at the level matching the clinical findings, and failure of at least 6 weeks of conservative therapy, or 3 months for certain fusion indications such as scoliosis, kyphosis and sub-axial instability. Computer-assisted surgical navigation is approvable only when fusion implants are placed during surgery, and it is not approvable during routine decompression surgery.
Aetna considers metal-on-metal hip resurfacing with an FDA-approved device a medically necessary alternative to total hip arthroplasty for physically active non-elderly adult members under 65 who meet the listed criteria, and experimental, investigational, or unproven for all other indications. The policy also lists shoulder resurfacing, knee, partial knee and patellar resurfacing, wrist capitate resurfacing, metatarsophalangeal joint resurfacing, facet joint resurfacing, talar inlay resurfacing and navigation during hip resurfacing as experimental, investigational, or unproven. The policy history shows an original effective date of 05/02/2003 and a last review date of 10/07/2026.
Medical Mutual of Ohio is emphasizing proper billing and documentation for diabetes glycemic status assessments to improve HEDIS scores. Providers should bill CPT 83036 for HbA1c lab tests along with specific CPT II codes based on A1c/GMI results, and ensure proper medical record documentation with specific dates.
Blue Cross Blue Shield of Wyoming is requesting providers use specific Category II codes (3044F, 3051F, 3052F, 3046F) with HbA1c lab tests (CPT 83036) to improve HEDIS scores for On-exchange and FEP members. The policy also announces upcoming UM tool updates for fall and provides coding advice for automated claims review starting in March.
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