Does Anthem BCBS require prior authorization for 99454?

Anthem BCBS lists 99454 on List of items and services that require prior authorization (Elevance CMS-0057-F list) for medicaid managed plans (list dated February 11, 2026). Verify with the payer before scheduling.

Does CalViva Health require prior authorization for 99454?

CalViva Health lists 99454 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 99454?

Community Health Plan of Imperial Valley lists 99454 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.

Does CountyCare Health Plan require prior authorization for 99454?

CountyCare Health Plan lists 99454 on CountyCare Prior Authorization Look-Up Tool (All Codes) for medicaid managed plans (list dated April 23, 2026). Verify with the payer before scheduling.

What insurance policy changes affect CPT 99454?

There are 22 tracked policy changes affecting CPT 99454, including updates from Independence Blue Cross, Arkansas Medicaid, Pennsylvania Medicaid (DHS). Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 99454?

Payers that have issued tracked updates for CPT 99454 include: Independence Blue Cross, Arkansas Medicaid, Pennsylvania Medicaid (DHS), Aetna, NY Medicaid, CareFirst BlueCross BlueShield, Blue Cross of Idaho, Nebraska Medicaid, Blue Cross & Blue Shield of Mississippi, Maryland Medicaid, Blue Cross Blue Shield of Rhode Island, Indiana Medicaid (IHCP), BCBS Arizona.

How do I get notified when CPT 99454 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 99454. 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 99454?

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

99454 Insurance Policy Changes

CPT 99454 is referenced in 22 tracked payer policy changes from Independence Blue Cross, Arkansas Medicaid, and 11 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 99454 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Independence Blue Cross · Effective Nov 30, 2026High impact
MA12.010e, Remote Physiologic Monitoring and Remote Therapeutic Monitoring
Effective 11/30/2026, Independence Blue Cross Medicare Advantage is updating medical policy MA12.010e to change remote patient monitoring (RPM and RTM) coverage from a blanket covered status to medically necessary with specific criteria. Coverage is now limited to patients with heart failure, hypertension, or diabetes mellitus, with 16 CPT/HCPCS codes now eligible only when specific diagnoses and clinical criteria are met. Billing teams must update authorization logic, documentation requirements, and claim submission workflows to reflect the new diagnosis-based eligibility rules.
Arkansas Medicaid · Effective Sep 1, 2026High impact
Coverage Added for Remote Patient Monitoring
Effective September 1, 2026, Arkansas Department of Human Services has expanded Medicaid coverage to include Remote Patient Monitoring services for CNMs, Nurse Practitioners, and Physicians serving female patients in diagnosis group 2011. Five new CPT codes (99091, 99453, 99454, 99457, 99458) are now reimbursable across three contract types (CNMW, MEDSV, NURSP).
Pennsylvania Medicaid (DHS) · Effective Aug 1, 2026High impact
MAB2026071001
Effective for dates of service on and after August 1, 2026, Pennsylvania Medical Assistance Fee-for-Service adds procedure codes and procedure code and modifier combinations from the 2026 HCPCS updates, adds other procedure codes based on clinical review or provider request, and end-dates a list of procedure codes. Prior authorization is required for codes 70471, 70472, 70473 and 75577, including their TC and 26 modifier versions. The Department removed listed provider type, specialty and place of service combinations from procedure code 77387 and changed the MA fees for 77387 (26), 77402, 77407 and 77412, with 77402 going from $21.50 to $60.36, 77407 from $32.50 to $227.68 and 77412 from $44.00 to $325.80.
Aetna · Effective May 31, 2026High impact
Remote Physiologic Monitoring (RPM) (CPB 1093, reviewed 2026-05-31)
Aetna has clarified its Remote Physiologic Monitoring (RPM) coverage policy (CPB 1093, effective 2026-05-31) establishing strict medical necessity criteria for three conditions: heart failure, hypertension, and diabetes. RPM is now only covered when using FDA-approved devices with automatic data transmission, documented patient consent, provider ordering/supervision, and clinical impact on treatment plans. Coverage is limited to one episode per patient per condition per provider per month. Billing teams must verify all criteria are met before submitting claims and ensure documentation supports medical necessity.
Independence Blue Cross · Effective Jan 1, 2026High impact
MA12.010d, Remote Patient Monitoring
Independence Blue Cross MA12.010d updates Remote Patient Monitoring (RPM) billing codes effective 01/01/2026. Six new CPT codes (98979, 98984, 98985, 98986, 99445, 99470) have been added for reimbursement consideration, and eight existing codes have had their narratives revised. RPM coverage remains limited to Medicare Advantage members with acute decompensated heart failure in home settings and requires program pre-approval submission to UMprogramsubmission@ibx.com.
Independence Blue Cross · Effective Jan 1, 2026High impact
00.01.52z, Bundled Procedure Codes
Independence Blue Cross updated policy 00.01.52z to 00.01.52ac effective 1/01/2026, reflecting annual CPT/HCPCS code updates. The policy adds 77417 to always-bundled procedures (Attachment A), removes six cardiology codes (92921, 92925, 92929, 92934, 92938, 92944), adds 18 codes to non-separately-reimbursable services (Attachment B), removes two codes from Attachment B, removes G0071 from Attachment C, and revises narrative descriptions for six procedure codes. Billing teams must immediately update system rules to reflect these code changes to avoid claim denials.
NY Medicaid · Effective Jan 1, 2026High impact
Expansion of Remote Patient Monitoring Delivered by Clinical Staff and for Prenatal/Postpartum Services
NYS Medicaid is expanding Remote Patient Monitoring (RPM) coverage effective January 1, 2026, by adding two new CPT codes (99470 and 99445) that allow billing for shorter monitoring durations. Code 99470 covers 10-19 minutes of clinical staff-delivered RPM, and code 99445 covers 2-15 days of prenatal/postpartum RPM monitoring. Medicaid Managed Care plans must implement compliance by March 1, 2026.
CareFirst BlueCross BlueShield · Effective Aug 1, 2025High impact
Maryland Medicaid enhanced reimbursement rates for eligible primary care providers, effective August 1, 2025
Maryland Medicaid has implemented enhanced reimbursement rates for eligible primary care providers effective August 1, 2025. The higher rates apply to evaluation and management codes 99202-99499 and G2211, with Managed Care Organizations required to pay these minimum rates to in-network PCPs.
Blue Cross of Idaho · Identified Sep 29, 2026High impact
MAPAP111 - Billing Requirements for Federally Qualified Health Centers (FQHCS) - Added FQHC Billing Guidelines document
Blue Cross of Idaho provider administrative policy MAP111 sets billing requirements for federally qualified health centers (FQHCs) submitting claims for qualifying visits under the CMS Prospective Payment System, for Medicare Advantage members. Qualifying FQHC claims must use type of bill 77X and include revenue code(s) 0519, 0521, 0522, 0524, 0525, 0527, 0528, and/or 0900, and listed qualifying services for Medicare Advantage patients must include the corresponding CMS PPS payment code (HCPC).
Nebraska Medicaid · Effective Jul 1, 2026Medium impact
Coverage for Remote Physiologic Monitoring
Nebraska Medicaid will begin covering Remote Physiologic Monitoring (RPM) services effective July 1, 2026, for patients with heart failure or hypertensive disorders of pregnancy. Six new billing codes (99453, 99454, 99455, 99457, 99458, 99470) are now available with specific documentation and eligibility requirements.
Blue Cross & Blue Shield of Mississippi · Effective Jan 1, 2026Medium impact
Telehealth: Remote Patient Monitoring Services
BCBSMS policy L.2.04.439 covers remote patient monitoring services, which must be prior authorized and ordered by a Physician, and must be performed by a Mississippi-licensed Provider affiliated with a Mississippi health care facility. An initial monitoring episode is allowed for up to 31 days, further monitoring requires an updated plan of care and re-authorization, and coverage is not provided beyond a six-month period. The 01/01/2026 update added CPT 98984, 98985, 98986 and 99445 and revised the descriptions of CPT 98976, 98977, 98980, 98981, 99453, 99454, 99457 and 99458.
Maryland Medicaid · Effective May 15, 2025Medium impact
Update to Reimbursement for Remote Patient Monitoring Services: Self-Measured Blood Pressure Codes
Maryland Medicaid has updated Remote Patient Monitoring (RPM) and Self-Measured Blood Pressure (SMBP) coverage, eliminating prior authorization requirements for RPM and adding new billable SMBP codes 99473 and 99474. Code S9110 is no longer covered for RPM services.
Aetna · Identified Oct 26, 2026Medium impact
Remote Physiologic Monitoring (RPM) (CPB 1093, reviewed 2026-06-01)
Aetna Clinical Policy Bulletin 1093 on remote physiologic monitoring (RPM), reviewed 2026-06-01, considers RPM medically necessary when all listed criteria are met, including a member with heart failure, hypertension or diabetes, an FDA-approved or cleared device capable of automatic data transmission, and documentation of patient consent in the medical record. The policy considers RPM experimental, investigational or unproven for conditions other than those listed, and for RPM using devices not approved or cleared by the FDA, and it states that coverage is limited to one episode of RPM per patient per condition per provider per month.
Blue Cross of Idaho · Identified Oct 6, 2026Medium impact
MAPAP113 - Billing Requirements for Rural Health Centers (RHCs) - Added language about preventive exams and revised billing instructions for care coordination, VCS, CoCM, telehealth, and vaccines per CMS coding updates.
Blue Cross of Idaho revised its Medicare Advantage billing policy for Rural Health Clinics in September 2026 to add preventive exam language and update how care coordination, virtual communication services, psychiatric collaborative care, telehealth and vaccines are billed, following CMS coding changes. The policy gives no single effective date for the September 2026 revision, but it lists code-specific dates of January 1, 2026 and October 1, 2026, both now passed. The entry for G0511 reads 'Oct. 1, 25', which is unclear, so confirm that date with Blue Cross of Idaho.
Blue Cross of Idaho · Identified Oct 6, 2026Medium impact
MAPAP111 - Billing Requirements for Federally Qualified Health Centers (FQHCs) - Added language about preventive exams
Blue Cross of Idaho's FQHC billing policy for Medicare Advantage claims, with the September 2026 revision that added language on preventive exams. Preventive exams (CPT 99381 through 99387) are billed separately on a CMS-1500 claim, and FQHC qualifying visits need the right type of bill, revenue code and CMS payment HCPCS code, because claims missing any of these are denied and returned for correction. The policy text states no effective date of its own, so confirm the current rules on the payer's site.
Aetna · Identified Oct 4, 2026Medium impact
Glaucoma Testing (CPB 0622, reviewed 2026-09-23)
Aetna considers computerized visual field examination, gonioscopy, measurement of the optic nerve head and retinal nerve fiber layer, pachymetry and tonometry medically necessary for evaluation of primary open-angle glaucoma. Aetna considers the following experimental, investigational or unproven: artificial intelligence-based detection of glaucoma, continuous monitoring of intra-ocular pressure, genotyping and genetic testing for glaucoma, home-based perimetry, home tonometry such as the Icare Home Tonometer, measurement of corneal hysteresis, ocular blood flow analyzers and tonometers, provocative tests, rapid campimetry, the RETeval portable electroretinogram device, and visual evoked potential testing. The listed CPT codes are covered when selection criteria are met, and ICD-10 codes H40.1110 through H40.1194 for primary open-angle glaucoma are covered when selection criteria are met.
Blue Cross of Idaho · Identified Sep 29, 2026Medium impact
MAPAP111 - Billing Requirements for Federally Qualified Health Centers (FQHCs) - Added telehealth clarification
Blue Cross of Idaho's billing policy for federally qualified health centers (FQHCs) on Medicare Advantage claims, last revised September 2026 to add preventive exam language. FQHC qualifying visits must carry the right type of bill, revenue code and CMS payment HCPCS code, and claims missing any of these are denied and returned for correction, so the FQHC billing team needs to confirm its claim setup against the current list.
Aetna · Identified Aug 17, 2026Medium impact
Glaucoma Testing (CPB 0622, reviewed 2025-09-25)
Aetna considers computerized visual field examination, gonioscopy, measurement of the optic nerve head and retinal nerve fiber layer, pachymetry, and tonometry medically necessary for evaluation of primary open-angle glaucoma. Aetna considers artificial intelligence-based glaucoma detection, continuous intraocular pressure monitoring, glaucoma genetic testing, home-based perimetry, home tonometry such as the Icare Home Tonometer, corneal hysteresis measurement, ocular blood flow analyzers, provocative tests, rapid campimetry, the RETeval device, and visual evoked potentials experimental, investigational, or unproven. CPT codes 76514, 92020, 92081, 92082, 92083, 92100, 92133 and 92134 are covered if selection criteria are met, and CPT codes 0198T, 0329T, 0464T, 0509T, 92145, 92273, 92274, 99453, 99454 and 99457 are not covered for the indications listed.
Aetna · Identified Aug 15, 2026Medium impact
Chronic Pain Rehabilitation Programs (CPB 0237, reviewed 2026-04-23)
Aetna's Clinical Policy Bulletin 0237 sets medical necessity criteria for chronic pain rehabilitation programs. Outpatient programs are medically necessary when the member has had chronic pain for more than 3 months, has documented failure or inadequate response to standard single-modality treatment, has persistent limitations in daily or social or vocational functioning, and has a physician referral and a pre-program psychological and behavioral health evaluation. Inpatient programs for up to 21 days require refractory pain plus two or more listed intractable pain criteria, and several conditions, including prior failure of an adequate multidisciplinary program, aggressive or violent behavior, and imminent suicidal tendencies, are considered not medically necessary.
Blue Cross Blue Shield of Rhode Island · Identified Jun 20, 2026Medium impact
January 2019
Effective April 1, 2019, the provider taxonomy code must be submitted on all claims. Reported as already effective in the historical source, Medicare Advantage claims for out-of-network payments require the Health Trio referral number in box 23 of the CMS-1500 form. January 2019 CPT and HCPCS code changes are effective January 1, 2019, and the code lists carry coverage designations such as Subject to Medical Review, Not Medically Necessary, Not Separately Reimbursed and Not Covered.
Indiana Medicaid (IHCP) · Identified Jun 19, 2026Medium impact
BT202158: IHCP updates Outpatient Fee Schedule
The IHCP reviewed the Outpatient Fee Schedule, found discrepancies, and will reflect the changes in the next regular update to that schedule. Codes listed twice on previous versions will appear only once, codes missing from the schedule are covered in the outpatient setting and can be billed for dates of service on or after the date listed for each code, and other listed codes are noncovered and will be added to the schedule. Codes that have been nationally end dated will be removed from the schedule, and Current Dental Terminology (CDT) codes cannot be billed on institutional claims (UB-04 claim form or electronic equivalent).
BCBS Arizona · Identified Jun 16, 2026Medium impact
Telehealth Services
BCBSAZ covers telehealth only as the member's benefit plan provides. Under the BlueCare Anywhere benefit, telehealth is covered when the Telehealth Services Administrator provides the service and determines the condition is appropriate, for a medical, therapy or psychiatry consultation. Under the in-network telehealth benefit, a service is covered when it would be covered in person and can be provided effectively by telehealth, through audio-visual services or limited audio-only services, and out-of-network non-emergency telehealth is not covered. The most recent review, dated 07/29/26, made no revisions.

Watch 99454

Get one email when a payer policy names 99454, a payer adds or drops it from a prior auth list, or Medicare changes its NCCI pairs, unit limit, payment or coverage articles.

See every payer rule for 99454

Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 99454 in one place.

See every payer rule

Get alerts for changes like this

Save a search and get email alerts when a new policy change matches your filters: daily or weekly, your choice, on every plan.

Create a free alert How Policy Monitoring works

MA12.010e, Remote Physiologic Monitoring and Remote Therapeutic Monitoring

Coverage Added for Remote Patient Monitoring

MAB2026071001

Remote Physiologic Monitoring (RPM) (CPB 1093, reviewed 2026-05-31)

MA12.010d, Remote Patient Monitoring

00.01.52z, Bundled Procedure Codes

Expansion of Remote Patient Monitoring Delivered by Clinical Staff and for Prenatal/Postpartum Services

Maryland Medicaid enhanced reimbursement rates for eligible primary care providers, effective August 1, 2025

MAPAP111 - Billing Requirements for Federally Qualified Health Centers (FQHCS) - Added FQHC Billing Guidelines document

Coverage for Remote Physiologic Monitoring

Telehealth: Remote Patient Monitoring Services

Update to Reimbursement for Remote Patient Monitoring Services: Self-Measured Blood Pressure Codes

Remote Physiologic Monitoring (RPM) (CPB 1093, reviewed 2026-06-01)

MAPAP113 - Billing Requirements for Rural Health Centers (RHCs) - Added language about preventive exams and revised billing instructions for care coordination, VCS, CoCM, telehealth, and vaccines per CMS coding updates.

MAPAP111 - Billing Requirements for Federally Qualified Health Centers (FQHCs) - Added language about preventive exams

Glaucoma Testing (CPB 0622, reviewed 2026-09-23)

MAPAP111 - Billing Requirements for Federally Qualified Health Centers (FQHCs) - Added telehealth clarification

Glaucoma Testing (CPB 0622, reviewed 2025-09-25)

Chronic Pain Rehabilitation Programs (CPB 0237, reviewed 2026-04-23)

January 2019

BT202158: IHCP updates Outpatient Fee Schedule

Telehealth Services

Prior authorization required

Prior authorization required

Prior authorization required

Does Anthem BCBS require prior authorization for 99454?

Does CalViva Health require prior authorization for 99454?

Does Community Health Plan of Imperial Valley require prior authorization for 99454?

Does CountyCare Health Plan require prior authorization for 99454?

What insurance policy changes affect CPT 99454?

Which payers have updated policy for CPT 99454?

How do I get notified when CPT 99454 policy changes?

Why do payers change policies for CPT 99454?