Does Anthem BCBS require prior authorization for 86316?

Anthem BCBS lists 86316 on Virginia Local Precertification/Prior Authorization List (HMO & EPO) for commercial plans, with conditions (list dated September 1, 2026). Verify with the payer before scheduling.

Does CalViva Health require prior authorization for 86316?

CalViva Health lists 86316 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 Community Health Plan of Imperial Valley require prior authorization for 86316?

Community Health Plan of Imperial Valley lists 86316 on Community Health Plan of Imperial Valley 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 86316?

There are 9 tracked policy changes affecting CPT 86316, including updates from Aetna, Blue Cross Blue Shield of Rhode Island, Blue Cross NC. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 86316?

Payers that have issued tracked updates for CPT 86316 include: Aetna, Blue Cross Blue Shield of Rhode Island, Blue Cross NC, Blue Cross & Blue Shield of Mississippi.

How do I get notified when CPT 86316 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 86316. 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 86316?

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.

PAYER POLICY CHANGES

86316 Insurance Policy Changes

CPT 86316 is referenced in 9 tracked payer policy changes from Aetna, Blue Cross Blue Shield of Rhode Island, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 86316 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Aetna · Effective Jul 31, 2026High impact
Nusinersen (Spinraza) (CPB 0915, reviewed 2026-07-31)
Aetna updated its Spinraza (nusinersen) policy for spinal muscular atrophy, effective July 31, 2026. The policy establishes clear precertification requirements, defines eligibility criteria for initial approval and continuation of therapy, specifies two dosing regimens (low-dose and high-dose), and designates administration locations through Aetna Institutes GCIT Network. Billing teams must implement prior authorization workflows and ensure claims include required baseline motor assessments (HINE-2, HFMSE, or CHOP-INTEND).
Blue Cross Blue Shield of Rhode Island · Effective Feb 1, 2026High impact
Medical policy updates
Multiple medical policies are being updated with changes to prior authorization requirements, covered diagnosis codes, and billing procedures across various specialties. Key changes include removal of prior authorization for several CPT codes, addition of new ICD-10 codes for breast cancer-related services, and updates to genetic testing coverage criteria.
Blue Cross Blue Shield of Rhode Island · Effective Jan 1, 2026High impact
Medical policy updates
Blue Cross Blue Shield Rhode Island is implementing major policy changes effective January 1, 2026, including new prior authorization requirements for physical therapy after 14 visits, removing prior authorization from numerous cardiology/radiology procedures, and updating coverage for various genetic testing and specialty procedures. Multiple CPT codes are changing authorization status and coverage requirements across Medicare Advantage and commercial plans.
Aetna · Identified Oct 4, 2026High impact
Nusinersen (Spinraza) (CPB 0915, reviewed 2026-09-09)
Aetna updated its clinical policy for nusinersen (Spinraza) for spinal muscular atrophy treatment, effective immediately. The policy establishes mandatory precertification requirements, specifies genetic documentation and baseline assessment requirements, defines two dosing regimens (low-dose and high-dose), and clarifies continuation criteria based on demonstrated clinical response. Billing teams must implement prior authorization workflows and ensure claims include required documentation of SMA type, genetic testing, motor assessment scores, and ventilation status.
Blue Cross NC · Effective Oct 15, 2025Medium impact
Medical Policy Update October 15, 2025
Blue Cross NC updated multiple medical policies effective October 15, 2025, including changes to cardiovascular risk assessment coverage criteria, coronavirus testing limitations, genetic testing terminology updates, and new CPT codes for prostate cancer testing. Most changes involve coverage criteria refinements and updated billing codes across various specialties.
Aetna · Identified Oct 3, 2026Medium impact
Salivary Tests (CPB 0608, reviewed 2026-09-23)
Aetna considers late night salivary cortisol medically necessary for diagnosing Cushing's syndrome. Aetna considers most other salivary tests experimental, investigational or unproven because their effectiveness has not been established, including salivary hormone tests for menopause and aging, salivary tests for cancer biomarkers, and salivary toxicology tests using the swish and spit method. Laboratory tests are not covered unless they are ordered by a physician or other qualified health professional.
Aetna · Identified Aug 18, 2026Medium impact
Hypoxic Ischemic Encephalopathy (CPB 0812, reviewed 2025-11-20)
Aetna considers total body cooling and selective head cooling medically necessary for neonates 28 days of age or younger with moderate or severe hypoxic ischemic encephalopathy (HIE). Aetna considers both cooling methods experimental, investigational, or unproven for other indications. The policy also lists adjunctive therapies for HIE, such as erythropoietin and magnesium, and several HIE biomarkers as experimental, investigational, or unproven.
Aetna · Identified Aug 16, 2026Medium impact
Salivary Tests (CPB 0608, reviewed 2025-10-01)
Aetna's Salivary Tests policy (CPB 0608) considers late night salivary cortisol medically necessary for diagnosing Cushing's syndrome, and lists CPT 82530 and 82533 as covered when selection criteria are met. Aetna considers many other salivary tests experimental, investigational or unproven, including salivary hormone tests for menopause and aging, salivary biomarker tests for cancers, salivary cortisol for diagnosis of adrenal insufficiency, and salivary toxicology tests using the swish and spit method such as the Quiksal Saliva Drug Test. Laboratory tests are not covered unless they are ordered by a physician or other qualified health professional.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance
The policy considers urinary tumor markers investigational for screening, diagnosis, and monitoring of bladder cancer, and for screening for precancerous colonic polyps. The FDA approved or cleared urinary tumor marker tests named in the policy are indicated as adjuncts to standard procedures for initial diagnosis of bladder cancer, surveillance of bladder cancer patients, or identification of colonic polyps, and laboratory-developed tests are offered without FDA regulatory review. A 05/29/2026 update changed the description of laboratory-developed tests and left the policy statement unchanged.

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Nusinersen (Spinraza) (CPB 0915, reviewed 2026-07-31)

Medical policy updates

Medical policy updates

Nusinersen (Spinraza) (CPB 0915, reviewed 2026-09-09)

Medical Policy Update October 15, 2025

Salivary Tests (CPB 0608, reviewed 2026-09-23)

Hypoxic Ischemic Encephalopathy (CPB 0812, reviewed 2025-11-20)

Salivary Tests (CPB 0608, reviewed 2025-10-01)

Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance

Prior authorization required in some cases

Prior authorization required