A04.72 Insurance Policy Changes

ICD-10 A04.72 is officially defined as "Enterocolitis due to Clostridium difficile, not specified as recurrent." code A04.72 is referenced in 4 tracked payer policy changes from Harvard Pilgrim Health Care, Excellus BlueCross BlueShield, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code A04.72 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Harvard Pilgrim Health Care · Effective Jan 1, 2026High impact
Point32Health Medical Necessity Guideline updates
Harvard Pilgrim and Tufts Health Plan Medical Necessity Guidelines changed, and prior authorization is newly required under the Carelon medical benefits management program for a number of codes and services for Harvard Pilgrim Commercial, effective March 1, 2026. Prior authorization was removed for CPT 99501, manual wheelchairs, and oxygen and respiratory therapy equipment effective January 1, 2026, and for Intensity-Modulated Radiation Therapy for all products as of December 31, 2025, because the listed codes are being discontinued.
Excellus BlueCross BlueShield · Effective Sep 17, 2026Medium impact
Fecal Microbiota Transplantation 2.01.48
Fecal microbiota transplantation (FMT) is considered medically appropriate for adults with recurrent Clostridioides difficile infection when the patient has had two or more recurrences after the initial episode despite standard antibiotic treatment, for a total of three or more episodes, and the appropriate donor stool screening has been completed. FMT is considered investigational for all other indications, including first-line treatment for CDI and the treatment of inflammatory bowel disease. The current effective date is September 17, 2026, and the most recent annual review kept the policy intent unchanged.
Aetna · Identified Aug 15, 2026Medium impact
Fecal Bacteriotherapy (CPB 0844, reviewed 2026-03-25)
Aetna's commercial clinical policy bulletin 0844 covers fecal bacteriotherapy. It considers fecal microbiota transplant medically necessary for Clostridium difficile infection (CDI) confirmed by a positive C. difficile toxin stool test that has recurred after at least one course of adequate antibiotic therapy. It considers a single rectal dose of Rebyota (fecal microbiota, live-jslm) medically necessary for preventing CDI when the policy's criteria are met, and it considers other listed indications, including alcoholic hepatitis, Crohn's disease, ulcerative colitis and irritable bowel syndrome, experimental, investigational, or unproven.
Aetna · Identified Aug 12, 2026Medium impact
Bezlotoxumab (Zinplava) (CPB 0914, reviewed 2026-01-07)
Aetna considers bezlotoxumab (Zinplava) medically necessary to reduce recurrence of C. difficile infection in members who are receiving antibacterial drug treatment for CDI and are at high risk for CDI recurrence. Criteria include age 1 year or older, a confirmed CDI diagnosis with 3 or more loose bowel movements in 24 or fewer hours, a positive toxigenic C. difficile stool test from a sample collected no more than 7 days prior, and at least one high-risk factor: age 65 or older, long term use of systemic antibacterial drugs, 1 or more CDI episodes in the previous 6 months, immunocompromise, clinically severe CDI (Zar score of 2 or greater), or a hypervirulent strain (ribotypes 027, 078 or 244). Bezlotoxumab is given in conjunction with standard of care antibiotics during the antibacterial treatment course, and other indications, combinations with other human monoclonal antibodies to C. difficile toxin, and repeat administration are considered experimental, investigational or unproven.

Watch A04.72

Get one email when a payer policy names A04.72, a payer adds or drops it from a prior auth list, or Medicare changes its NCCI pairs, unit limit, payment or coverage articles.

No account needed. We send a confirmation link first, and every email has a one-click stop link.

FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code A04.72?

There are 4 tracked policy changes affecting code A04.72, including updates from Harvard Pilgrim Health Care, Excellus BlueCross BlueShield, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code A04.72?

Payers that have issued tracked updates for code A04.72 include: Harvard Pilgrim Health Care, Excellus BlueCross BlueShield, Aetna.

How do I get notified when code A04.72 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code A04.72. 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 code A04.72?

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.

All billing codes J3590 C9399 J3490 99215 99213 99202

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

Point32Health Medical Necessity Guideline updates

Fecal Microbiota Transplantation 2.01.48

Fecal Bacteriotherapy (CPB 0844, reviewed 2026-03-25)

Bezlotoxumab (Zinplava) (CPB 0914, reviewed 2026-01-07)

What insurance policy changes affect code A04.72?

Which payers have updated policy for code A04.72?

How do I get notified when code A04.72 policy changes?

Why do payers change policies for code A04.72?