C48.1 Insurance Policy Changes

ICD-10 C48.1 is officially defined as "Malignant neoplasm of specified parts of peritoneum." code C48.1 is referenced in 9 tracked payer policy changes from Excellus BlueCross BlueShield, Independence Blue Cross, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C48.1 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Excellus BlueCross BlueShield · Effective Aug 20, 2026Medium impact
Breast Reconstruction Surgery and Prophylactic Breast Cancer Risk-Reducing Mastectomy 10.01.01
Excellus policy 10.01.01 considers reconstructive breast surgery during or after mastectomy, including partial mastectomy for benign or malignant disease, medically appropriate. Covered services may include breast implants, abdominal flap reconstruction, chest wall reconstruction, nipple and areola reconstruction and tattooing, surgery for symmetry of the opposite breast, basic breast prostheses, mastectomy bras, and treatment of physical complications of mastectomy including lymphedema. A risk-reducing mastectomy is considered medically appropriate for individuals with lobular carcinoma in situ, a known BRCA1 or BRCA2 variant, another high-risk gene variant, or chest radiotherapy between ages 10 and 30, and the 08/20/26 annual review states that policy intent is unchanged.
Independence Blue Cross · Effective Jun 16, 2025Medium impact
MA07.017g, Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
Independence Blue Cross Medicare Advantage has expanded HIPEC (hyperthermic intraperitoneal chemotherapy) coverage to include peritoneal carcinomatosis of gastric origin as medically necessary (previously experimental). The policy also refined ovarian/fallopian tube cancer coverage headers and removed eight ICD-10 codes. Effective June 16, 2025, gastric peritoneal carcinomatosis claims now require specific criteria: PCI ≤10, no extraperitoneal metastasis, and expected complete cytoreduction.
Independence Blue Cross · Effective Jun 16, 2025Medium impact
11.00.13k, Hyperthermic Intraperitoneal Chemotherapy for Select Intra-abdominal and Pelvic Malignancies
Independence Blue Cross expanded coverage for hyperthermic intraperitoneal chemotherapy (HIPEC) by reclassifying peritoneal carcinomatosis of gastric origin from experimental/investigational to medically necessary, effective June 16, 2025. The policy also clarified coverage headers for ovarian, fallopian tube, and primary peritoneal cancers, and removed 8 ICD-10 diagnosis codes from the policy document.
Independence Blue Cross · Effective Jun 16, 2025Medium impact
MA07.017g, Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
Independence Blue Cross Medicare Advantage policy MA07.017g has been reissued with expanded coverage for HIPEC (hyperthermic intraperitoneal chemotherapy). Key change: peritoneal carcinomatosis of gastric origin moved from experimental/investigational to medically necessary status, effective June 16, 2025. Eight ICD-10 codes were removed from the policy. Coverage criteria now include specific requirements for gastric origin cases (PCI ≤10, no extraperitoneal metastasis, expected complete cytoreduction).
Independence Blue Cross · Effective Jun 16, 2025Medium impact
11.00.13k, Hyperthermic Intraperitoneal Chemotherapy for Select Intra-abdominal and Pelvic Malignancies
Independence Blue Cross expanded coverage for HIPEC (hyperthermic intraperitoneal chemotherapy) by reclassifying gastric peritoneal carcinomatosis from experimental/investigational to medically necessary, effective June 16, 2025. The policy also clarified ovarian/fallopian tube cancer coverage and removed 8 ICD-10 codes that are no longer applicable to this procedure.
Aetna · Identified Oct 8, 2026Medium impact
Docetaxel (CPB 0956, reviewed 2026-10-05)
For commercial medical plans, docetaxel (Beizray, Docivyx, Taxotere, or generic docetaxel) is considered medically necessary for the listed cancer indications, including breast cancer, non-small cell lung cancer, prostate cancer, gastric cancer, head and neck cancer, ovarian cancer, small cell lung cancer, and soft tissue sarcoma. Breast cancer requires the disease-status criteria stated in the policy, and continuation of therapy is considered medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen. All other indications are considered experimental, investigational, or unproven.
Aetna · Identified Aug 15, 2026Medium impact
Ipilimumab (Yervoy) (CPB 0815, reviewed 2026-07-16)
Aetna's Clinical Policy Bulletin 0815 covers ipilimumab (Yervoy) for commercial medical plans. It considers ipilimumab medically necessary for the cancer indications listed in the policy, many of them in combination with nivolumab, and considers continued treatment medically necessary for members requesting reauthorization when there is no evidence of unacceptable toxicity or disease progression. It considers ipilimumab experimental, investigational, or unproven for indications such as glioblastoma, pancreatic cancer, and prostate cancer, and for use with bevacizumab, vemurafenib, dabrafenib, or trametinib.
Aetna · Identified Aug 13, 2026Medium impact
Paclitaxel, Albumin-Bound (CPB 0834, reviewed 2026-05-28)
Aetna considers albumin-bound paclitaxel (Abraxane or generic albumin-bound paclitaxel) medically necessary for the cancers listed in its initial approval criteria, including Kaposi sarcoma, breast cancer, cutaneous melanoma, endometrial carcinoma, ovarian, fallopian tube and primary peritoneal cancer, biliary tract cancers, non-small cell lung cancer, pancreatic adenocarcinoma, small bowel adenocarcinoma, uveal melanoma, ampullary adenocarcinoma, cervical cancer, bladder cancer and vaginal cancer, when each cancer's stated criteria are met. All other indications are considered experimental, investigational, or unproven, including small cell lung cancer, prostate cancer, soft-tissue sarcoma and gastric cancer. Continuation of therapy is medically necessary for an approved indication when there is no evidence of unacceptable toxicity or disease progression on the current regimen.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency, NTRK)
BRCA1 and BRCA2 variant analysis (germline, or somatic using tumor tissue) and homologous recombination deficiency analysis of tumor tissue may be considered medically necessary for individuals with advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer to select treatment with FDA-approved targeted therapies. NTRK1, NTRK2 and NTRK3 gene fusion analysis of tumor tissue was added in the 02/03/2025 policy update and may be considered medically necessary for the same population to select FDA-approved targeted therapies. BRCA1/2 variant analysis using circulating tumor DNA may be considered medically necessary when tissue-based analysis is not clinically feasible, while all other uses of these tests to guide targeted therapy, and simultaneous liquid and tumor biopsy testing outside paired or concurrent somatic-germline testing, are considered investigational.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code C48.1?

There are 9 tracked policy changes affecting code C48.1, including updates from Excellus BlueCross BlueShield, Independence Blue Cross, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code C48.1?

Payers that have issued tracked updates for code C48.1 include: Excellus BlueCross BlueShield, Independence Blue Cross, Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code C48.1 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C48.1. 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 C48.1?

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

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Breast Reconstruction Surgery and Prophylactic Breast Cancer Risk-Reducing Mastectomy 10.01.01

MA07.017g, Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies

11.00.13k, Hyperthermic Intraperitoneal Chemotherapy for Select Intra-abdominal and Pelvic Malignancies

MA07.017g, Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies

11.00.13k, Hyperthermic Intraperitoneal Chemotherapy for Select Intra-abdominal and Pelvic Malignancies

Docetaxel (CPB 0956, reviewed 2026-10-05)

Ipilimumab (Yervoy) (CPB 0815, reviewed 2026-07-16)

Paclitaxel, Albumin-Bound (CPB 0834, reviewed 2026-05-28)

Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency, NTRK)

What insurance policy changes affect code C48.1?

Which payers have updated policy for code C48.1?

How do I get notified when code C48.1 policy changes?

Why do payers change policies for code C48.1?