What insurance policy changes affect CPT 86812?

There are 33 tracked policy changes affecting CPT 86812, including updates from Ambetter, Aetna, Blue Cross Blue Shield of Rhode Island. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 86812?

Payers that have issued tracked updates for CPT 86812 include: Ambetter, Aetna, Blue Cross Blue Shield of Rhode Island, Blue Cross & Blue Shield of Mississippi.

How do I get notified when CPT 86812 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 86812. You will receive a daily digest email whenever a new policy change references this code.

Why do payers change policies for CPT 86812?

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.

86812 Insurance Policy Changes

CPT 86812 is referenced in 33 tracked payer policy changes from Ambetter, Aetna, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 86812 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

High impact
Effective 10/1/26: Removal of Prior Authorization Requirement for Certain Procedures
Ambetter·Effective Oct 1, 2026
Effective October 1, 2026, Superior HealthPlan will remove prior authorization requirements for 13 specific procedure codes across Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter Health plans. Billing teams must update their prior authorization workflows to stop requiring PA for these codes to avoid unnecessary delays and claim processing issues.
High impact
Q3 2026 Provider Newsletter
Ambetter·Effective Oct 1, 2026
Ambetter of Alabama has implemented multiple policy updates effective October 1, 2026 and December 5, 2026, including prior authorization requirement changes for genetic testing and surgical procedures, plus new site-of-care selection requirements for musculoskeletal surgeries. The billing team must update systems to remove PA requirements for genetic testing codes, add PA requirements for specific sinus surgery codes, and implement new authorization workflows for orthopedic procedures starting in December.
High impact
Effective October 1, 2026: Removal of Prior Authorization Requirement for Certain Procedures
Ambetter·Effective Oct 1, 2026
Effective October 1, 2026, Superior HealthPlan (Ambetter Health, Medicaid, CHIP) is removing prior authorization requirements for specific procedures across multiple service categories including genetic analysis, home services, transplant services, behavioral health, sleep medicine, durable medical equipment, and hearing services. Billing teams must update systems to stop requesting prior authorization for the listed procedure codes to avoid unnecessary delays and claim processing issues.
Medium impact
Important Prior Authorization Updates
Ambetter·Effective Oct 1, 2026
Ambetter from Magnolia Health is updating prior authorization requirements effective October 1, 2026. Genetic testing (CPT 81378-81383, 86812-86813, 86817), home services (S9211, S9213, S9214), and transplant services (CPT 38208) no longer require prior authorization, while sinus surgery (CPT 31297) now requires prior authorization. These changes standardize PA requirements across markets and lines of business.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter from Buckeye Health Plan is removing prior authorization requirements for genetic testing, obstetrical home services, and transplant services for participating providers effective October 1, 2026. Simultaneously, prior authorization is now required for sinus surgery (CPT 31297). These changes aim to reduce administrative burden and create uniform PA requirements across markets.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter from Coordinated Care Corporation is updating prior authorization requirements effective October 1, 2026. Key changes include removing PA requirements for genetic testing (86812, 86813, 86817), home services (S9211, S9213, S9214), and transplant services (38208), while maintaining PA requirements for sinus surgery procedures (31276, 31296, 31297, 31298). These changes aim to reduce administrative burden and create uniform PA requirements across markets.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter of Tennessee is updating prior authorization (PA) requirements effective October 1, 2026, removing PA requirements for genetic testing, home services, and medical transportation, while adding PA requirement for sinus surgery (CPT 31297). These changes aim to reduce administrative burden and create uniform PA requirements across markets.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter from Magnolia Health is removing prior authorization requirements for genetic testing (86812, 86813, 86817), home services (S9211, S9213, S9214), and transplant services (38208) effective October 1, 2026. Simultaneously, prior authorization is now required for sinus surgery (31297). These changes aim to reduce administrative burden and create uniform PA requirements across markets.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter from WellCare of Kentucky is updating prior authorization (PA) requirements effective October 1, 2026. Key changes include: removing PA requirements for genetic testing, home services, and transplant services; adding PA requirement for pain management surgery (nervous system); and adding PA requirement for sinus surgery procedures. These changes aim to reduce administrative burden and create uniform PA requirements across markets.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter Health is updating prior authorization (PA) requirements effective October 1, 2026, removing PA requirements for genetic testing, home services, and transplant services while adding PA requirements for specific sinus surgery procedures. These changes aim to reduce administrative burden and create uniform PA requirements across markets and lines of business.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter of Illinois is implementing significant prior authorization (PA) changes effective October 1, 2026, removing PA requirements for genetic testing, home services, and transplant procedures while adding PA requirements for sinus surgery procedures. These changes aim to reduce administrative burden and create uniform PA requirements across markets.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter from Peach State Health Plan is removing prior authorization requirements for three service categories effective October 1, 2026: Genetic Analysis (CPT 86812, 86813, 86817), Home Services (HCPCS S9211, S9213, S9214), and Transplant Services (CPT 38208). This change simplifies the PA process and reduces administrative burden for providers.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter Health is updating prior authorization requirements effective October 1, 2026, removing PA requirements for genetic testing, home services, and transplant services while maintaining PA requirements for hospice/home health and tonsil/adenoid procedures. This change aims to reduce administrative burden and create uniform PA requirements across markets and lines of business.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter of Alabama is updating prior authorization (PA) requirements effective October 1, 2026, removing PA requirements for genetic testing (CPT 86812, 86813, 86817) and transplant services (CPT 38208), while adding PA requirements for sinus surgery procedures (CPT 31296, 31297). These changes aim to reduce administrative burden and standardize PA processes across markets.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter from WellCare of New Jersey is removing prior authorization requirements for three service categories effective October 1, 2026: Genetic Analysis (CPT 86812, 86813, 86817), Home Services (HCPCS S9211, S9213, S9214), and Transplant Services (CPT 38208). This change simplifies the PA process and reduces administrative burden for providers.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter from NH Healthy Families is eliminating prior authorization requirements for genetic testing (CPT 86812, 86813, 86817), home visit services (HCPCS S9211, S9213, S9214), and transplant services (CPT 38208), while adding new PA requirements for sinus surgery procedures (CPT 31276, 31296, 31297, 31298). These changes take effect October 1, 2026, and aim to reduce administrative burden and streamline approval processes.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter Health is streamlining prior authorization (PA) requirements effective October 1, 2026, by removing PA requirements for genetic testing, home services, and transplant services, while adding PA requirements for specific sinus surgery procedures. This change simplifies PA processes across markets and aims to reduce administrative burden while maintaining appropriate clinical review.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter of North Carolina is removing prior authorization requirements for genetic testing, home services, and transplant procedures effective October 1, 2026, while adding a new PA requirement for sinus surgery (CPT 31297). These changes aim to reduce administrative burden and streamline the PA process across markets.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter from Louisiana Healthcare Connections is implementing significant prior authorization (PA) changes effective October 1, 2026. Genetic testing, home services, and transplant services will no longer require prior authorization, while sinus surgery procedures (codes 31276, 31296, 31297, 31298) will now require PA. The insurer is streamlining PA requirements across markets and lines of business to reduce administrative burden and enable faster processing.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter Health is updating prior authorization requirements effective October 1, 2026. The changes remove PA requirements for genetic testing (86812, 86813, 86817), home services (S9211, S9213, S9214), and transplant services (38208), while adding PA requirements for sinus surgery procedures (31276, 31296, 31297, 31298). These changes aim to reduce administrative burden and create uniform PA requirements across markets.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter of Oklahoma is updating prior authorization requirements effective October 1, 2026, removing PA requirements for genetic testing, home services, and transplant services, while adding PA requirements for specific sinus surgery procedures. These changes aim to reduce administrative burden and streamline the PA process across markets and lines of business.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter from SilverSummit Healthplan is removing prior authorization requirements for genetic testing, home services, and transplant services effective October 1, 2026, while adding PA requirements for specific sinus and facial/cranial procedures. This streamlines the authorization process across markets and lines of business to reduce administrative burden and improve claim processing speed.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter from Meridian is eliminating prior authorization requirements for genetic testing, home visit services, and transplant services effective October 1, 2026, while adding PA requirements for sinus surgery procedures. The changes aim to reduce administrative burden and create uniform PA requirements across markets and lines of business.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter Health of Delaware is updating prior authorization (PA) requirements effective October 1, 2026. Genetic testing (CPT 86812, 86813, 86817) and home visit services (HCPCS S9211, S9213, S9214) are moving to NO PA REQUIRED, while sinus surgery procedures (CPT 31276, 31296, 31297, 31298) now require PA. Changes aim to reduce administrative burden and create uniform PA requirements across markets.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter from Absolute Total Care is removing prior authorization requirements for genetic testing, home services, and transplant services effective October 1, 2026, while adding prior authorization requirements for specific sinus surgery procedures. These changes aim to reduce administrative burden and streamline the PA process across markets and lines of business.
Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter·Effective Oct 1, 2026
Ambetter from Arizona Complete Health is removing prior authorization requirements for genetic testing (CPT 86812, 86813, 86817), home services (HCPCS S9211, S9213, S9214), and transplant services (CPT 38208), while adding prior authorization requirements for sinus surgery procedures (CPT 31276, 31296, 31297, 31298). These changes take effect October 1, 2026, and aim to reduce administrative burden and simplify the PA process across markets and lines of business.
Medium impact
Important Prior Authorization Updates (Effective October 1, 2026)
Ambetter·Effective Oct 1, 2026
Ambetter Health is simplifying prior authorization requirements effective October 1, 2026, by removing PA requirements for genetic testing, home services, and transplant services, while adding PA requirements for specific sinus surgery procedures (31296, 31297). This change aims to reduce administrative burden and create uniform PA requirements across all markets and lines of business.
High impact
Rheumatic Diseases: Selected Tests (CPB 0866, reviewed 2025-12-22)
Aetna·Effective Dec 22, 2025
Aetna's updated Rheumatic Diseases policy (CPB 0866, effective 2025-12-22) clarifies coverage for specific rheumatologic tests. Anti-CCP antibodies (CPT 86200) remain covered for rheumatoid arthritis diagnosis, HLA-B27 testing is covered for ankylosing spondylitis and Reiter's syndrome, myositis antibody panels are covered for inflammatory myopathy, anti-dsDNA antibodies are covered for SLE evaluation, and UBA1 mutation testing (CPT 0500U) is newly covered for VEXAS syndrome detection. However, numerous investigational tests including Avise panels, aiSLE DX, PrismRA, and other biomarker panels are now explicitly listed as non-covered (experimental/investigational).
Medium impact
Medical policy updates
Blue Cross Blue Shield of Rhode Island·Effective May 1, 2025
BCBSRI has updated medical policies effective May 1 and June 1, 2025, affecting prior authorization requirements for durable medical equipment, expanding covered diagnosis codes for CA-125 testing and cardiovascular biomarker testing, and adding new requirements for human leukocyte antigen testing with mandatory modifier usage.
Medium impact
Nonmyeloablative Allogeneic Transplants of Hematopoietic Stem-Cells for Treatment of Malignancy
Blue Cross & Blue Shield of Mississippi·Identified Jun 20, 2026
Blue Cross & Blue Shield of Mississippi updated their policy on nonmyeloablative allogeneic stem cell transplants for cancer treatment. The policy requires prior authorization through Case Management for all covered transplant procedures and evaluations, and specifies that the procedure is only medically necessary for patients who would otherwise meet criteria for high-dose chemotherapy and allogeneic stem cell transplantation.
Medium impact
Hematopoietic Stem-Cell Transplantation for Breast Cancer
Blue Cross & Blue Shield of Mississippi·Identified Jun 20, 2026
Blue Cross Blue Shield of Mississippi has updated their policy on hematopoietic stem cell transplantation for breast cancer, explicitly stating that autologous transplants are not medically necessary and allogeneic transplants are investigational for all stages of breast cancer. Prior authorization through Case Management is required for any covered transplant procedures.
Medium impact
Placental and Umbilical Cord Blood as a Source of Stem Cells
Blue Cross & Blue Shield of Mississippi·Identified Jun 20, 2026
Blue Cross Blue Shield of Mississippi updated their policy on placental and umbilical cord blood stem cell transplantation, requiring prior authorization through case management for all covered transplant procedures and evaluations. The policy clarifies that cord blood stem cell transplantation is medically necessary only for appropriate allogeneic transplant indications, while prophylactic collection and storage is considered not medically necessary.
Low impact
Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas
Blue Cross & Blue Shield of Mississippi·Identified Jun 20, 2026
Blue Cross Blue Shield of Mississippi updated their policy on autologous hematopoietic stem-cell transplantation for malignant astrocytomas and gliomas, confirming these procedures remain investigational and not covered. The policy requires prior authorization through Case Management for any transplant procedures or evaluations.

All billing codes J3590 99213 99214 99212 99202 99203

Get alerts for changes like this

Save a search and receive a daily digest whenever a new policy change matches your filters.

Create a free alert

Effective 10/1/26: Removal of Prior Authorization Requirement for Certain Procedures

Q3 2026 Provider Newsletter

Effective October 1, 2026: Removal of Prior Authorization Requirement for Certain Procedures

Important Prior Authorization Updates

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates (Effective October 1, 2026)

Rheumatic Diseases: Selected Tests (CPB 0866, reviewed 2025-12-22)

Medical policy updates

Nonmyeloablative Allogeneic Transplants of Hematopoietic Stem-Cells for Treatment of Malignancy

Hematopoietic Stem-Cell Transplantation for Breast Cancer

Placental and Umbilical Cord Blood as a Source of Stem Cells

Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas