C72.0 Insurance Policy Changes

ICD-10 C72.0 is officially defined as "Malignant neoplasm of spinal cord." code C72.0 is referenced in 20 tracked payer policy changes from Excellus BlueCross BlueShield, Health Net, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C72.0 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 Jan 1, 2027Medium impact
Spine Procedures for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) Members - (Effective Date - 2027-01-01) 7.01.126
Excellus BlueCross BlueShield policy 7.01.126 sets medical necessity criteria for spine procedures for Managed Medicaid, Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) members, with a current effective date of January 1, 2027. It covers cervical arthrodesis, corpectomy, disc arthroplasty, anterior and posterior cervical decompression, lumbar arthrodesis, lumbar decompression, lumbar discectomy, lumbar osteotomy and pediatric scoliosis surgery, and it considers percutaneous lumbar disc decompression and discectomy investigational. A policy edit dated 10/15/26 removed all site-of-care criteria and smoking-status criteria from lumbar decompression requirements.
Health Net · Identified Jun 20, 2026High impact
21-139 Medical Policies - 4th Quarter 2020
Health Net updated multiple medical policies in Q4 2020, affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties including oxygen therapy, allergy testing, bariatric surgery, wound care, and various diagnostic procedures.
Health Net · Identified Jun 20, 2026High impact
21-141 Medical Policies - 4th Quarter 2020
Health Net updated multiple medical policies in Q4 2020, affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties including oxygen therapy, allergy testing, bariatric surgery, and wound care. Most changes involve revised medical necessity criteria and updated CPT/ICD-10 codes that require immediate attention for proper billing and authorization processes.
Health Net · Identified Jun 20, 2026High impact
21-142 Medical Policies - 4th Quarter 2020
CalViva Health updated multiple medical policies for Q4 2020 affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties. Key changes include revised oxygen therapy criteria, new ambulatory surgery center redirection requirements, updated bariatric surgery protocols, and modified coverage for various diagnostic and therapeutic services.
Excellus BlueCross BlueShield · Effective Oct 15, 2026Medium impact
Lumbar Decompression - (Effective Date - 2026-10-15) 7.01.113
Excellus BlueCross BlueShield's Lumbar Decompression policy (7.01.113) is effective October 15, 2026. The June 18, 2026 annual review added criteria to the physical exam findings for primary lumbar decompression for radiculopathy and added medically necessary criteria for lumbar corpectomy. The policy also states that Coflex interlaminar devices are medically appropriate only under specific criteria, and that stabilization and distraction implants used after decompression or as stand-alone procedures are investigational.
Blue Cross Blue Shield of North Dakota · Effective Mar 17, 2026Medium impact
Pharmacy Policies Available Online
Commercial prior authorization medical drug policies have revisions effective March 17, 2026, with many policies adding the Appendix A NQTL Factor Checklist, showing the number of days allowed for authorization durations, and replacing 'coverage' with 'prior authorization validity' in the initial and renewal criteria. Clinical updates include Eylea HD for macular edema following retinal vein occlusion, Breyanzi for relapsed or refractory marginal zone lymphoma, and new appendiceal neoplasm and cancer indications with ICD-10 codes D37.3 and Z85.038. Commercial post service claim edit policies for Trogarzo have revisions effective Feb. 1, 2026.
Excellus BlueCross BlueShield · Effective Nov 16, 2025Medium impact
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy 6.01.12
Excellus BlueCross BlueShield stereotactic radiosurgery and stereotactic body radiation therapy medical policy 6.01.12 has a current effective date of November 16, 2025. Its October 16, 2025 annual review removed life expectancy criteria from the policy criteria. SRS is considered medically appropriate for specified benign, brain and neurologic indications, SBRT is considered medically appropriate for specified extracranial cancers and oligometastatic disease, and SBRT is considered not medically necessary for indications including extrahepatic bile duct cancer, gallbladder cancer and chronic pain.
Aetna · Identified Oct 22, 2026Medium impact
Ziconotide (Prialt) (CPB 0712, reviewed 2026-10-14)
Aetna considers intrathecal ziconotide (Prialt) medically necessary for members with severe chronic pain that is intolerant of or refractory to other treatments, such as systemic analgesics, adjunctive therapies, or intrathecal morphine. Aetna considers it not medically necessary for members with a pre-existing history of psychosis, an infection at the micro-infusion injection site, uncontrolled bleeding diathesis, or spinal canal obstruction. Aetna considers intrathecal ziconotide experimental, investigational, or unproven for autism, epilepsy, Irukandji syndrome, migraines, primary lateral sclerosis, stroke and other indications, and considers the intrathecal combination of ziconotide, morphine and levobupivacaine experimental for cancer-related refractory pain.
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 19, 2026Medium impact
Brachytherapy (CPB 0371, reviewed 2026-05-20)
Aetna considers brachytherapy medically necessary for breast, esophageal, eye tumors, genitourinary cancers other than bladder, gynecologic, head and neck, respiratory and digestive tract, and soft tissue sarcoma indications when the EviCore Healthcare Radiation Therapy Clinical Guidelines criteria are met. It also considers brachytherapy medically necessary for skin cancer where surgical resection and photon or electron beam techniques are contraindicated, and for stenotic obstruction after lung transplantation refractory to other treatments. Brachytherapy for bladder cancer, bone metastases, brain tumors, leukemia, lymphoma, multiple myeloma, pancreatic cancer, keloids, palmoplantar pustulosis, spinal tumors and spinal metastases, and subfoveal choroidal neovascularization secondary to age-related macular degeneration is considered experimental, investigational or unproven, and electronic brachytherapy is considered experimental, investigational or unproven for breast cancer and all other indications.
Aetna · Identified Aug 19, 2026Medium impact
Ziconotide (Prialt) (CPB 0712, reviewed 2026-03-11)
Intrathecal ziconotide (Prialt) is considered medically necessary for members with severe chronic pain that is intolerant of or refractory to other treatments, such as systemic analgesics, adjunctive therapies, or intrathecal morphine. It is considered not medically necessary for members with a pre-existing history of psychosis, an infection at the micro-infusion injection site, uncontrolled bleeding diathesis, or spinal canal obstruction. Use for autism, epilepsy, Irukandji syndrome, migraines, primary lateral sclerosis, and stroke is considered experimental, investigational, or unproven, as is the intrathecal combination of ziconotide, morphine, and levobupivacaine for cancer-related refractory pain.
Aetna · Identified Aug 17, 2026Medium impact
Hematopoietic Cell Transplantation for Solid Tumors in Adults (CPB 0811, reviewed 2025-12-03)
Aetna's Clinical Policy Bulletin 0811 considers autologous or allogeneic hematopoietic stem cell transplant, both ablative and non-myeloablative, experimental, investigational, or unproven for the following adult solid tumors: bile duct (cholangiocarcinoma), breast, central nervous system tumors, cervix, colon, esophagus, fallopian tube, gallbladder, kidney, liver, lung, melanoma, nasopharynx, neuroendocrine tumors, pancreas, paranasal sinus, prostate, rectum, soft tissue sarcomas, stomach, thymus, thyroid, tumors of unknown primary origin, and uterus. Aetna considers autologous hematopoietic stem cell transplant medically necessary in young adults with primitive neuroectodermal tumors, medulloblastoma, and Ewing sarcoma family of tumors when criteria are met in CPB 0496.
Aetna · Identified Aug 17, 2026Medium impact
Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors (CPB 0496, reviewed 2026-08-06)
Aetna considers autologous hematopoietic cell transplantation medically necessary as consolidation therapy for high-risk neuroblastoma when the member meets the transplanting institution's protocol selection criteria. Without a protocol, it is considered medically necessary when the stated criteria are met, including tandem autologous transplants for the common high-risk group and a single autologous transplant for the special high-risk groups. Autologous transplant is not medically necessary for members with progressive disease during or at the end of induction therapy. Autologous transplant is also addressed for chemosensitive relapsed or refractory neuroblastoma, relapsed or progressive chemosensitive Ewing's sarcoma family of tumors that is not widely metastatic, primitive neuroectodermal tumors including medulloblastoma and pineoblastoma, ependymoma in members ineligible for radiotherapy, extraocular retinoblastoma, and progressive or relapsed chemosensitive Wilms' tumor. Allogeneic hematopoietic cell transplantation for ependymoma, Ewing's sarcoma family of tumors, neuroblastoma, primitive neuroectodermal tumors, retinoblastoma and Wilms' tumor, adoptive cellular immunotherapy following transplantation for childhood solid tumors, and autologous transplantation for soft tissue sarcomas are considered experimental, investigational, or unproven.
Aetna · Identified Aug 17, 2026Medium impact
Temozolomide (Temodar) Injection (CPB 0876, reviewed 2026-06-03)
Aetna's Clinical Policy Bulletin 0876 considers temozolomide (Temodar) injection medically necessary for brain metastases from solid tumors, metastatic or unresectable cutaneous melanoma as single agent subsequent therapy, second-line Ewing sarcoma in combination with irinotecan with or without vincristine, mycosis fungoides or Sezary syndrome with CNS involvement as single agent subsequent therapy, high-risk neuroblastoma in combination with irinotecan, dinutuximab and sargramostim or with irinotecan, naxitamab-gqgk and sargramostim, unresectable or metastatic pheochromocytoma or paraganglioma as single agent first-line therapy, relapsed or primary progressive small cell lung cancer as single agent subsequent therapy, advanced, recurrent, metastatic or inoperable uterine sarcoma as single agent subsequent therapy, and unresectable or metastatic uveal melanoma as a single agent. Aetna considers all other indications experimental, investigational or unproven, including chronic lymphocytic leukemia, diffuse large B-cell lymphoma, metastatic colorectal cancer and pituitary tumors. Continuation of therapy is considered medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen.
Aetna · Identified Aug 16, 2026Medium impact
Ribavirin for Inhalation Use (CPB 0155, reviewed 2026-04-21)
Aetna considers ribavirin for inhalation medically necessary for the treatment of hospitalized infants and young children with severe lower respiratory tract infections due to respiratory syncytial virus (RSV). Aetna considers all other indications experimental, investigational, or unproven, including the cationic liposome encapsulated ribavirin spray for the treatment of acute pneumonia. Ribavirin for inhalation is not indicated for use in adults.
Aetna · Identified Aug 13, 2026Medium impact
Plerixafor (CPB 0779, reviewed 2026-02-13)
Aetna's policy covers plerixafor (Mozobil or generic plerixafor) for hematopoietic stem cell mobilization when it is given after a granulocyte-colony stimulating factor such as filgrastim, after chemo-mobilization, or as part of a gene therapy protocol, and when it is not used beyond 4 consecutive days or after stem cell harvest or apheresis is complete. Continuation of therapy is considered medically necessary for members who meet the initial selection criteria. Aetna considers plerixafor experimental, investigational or unproven for all other indications, including the conditions listed in the policy such as acute leukemias, sickle cell disease, WHIM syndrome and neutropenia treatment.
Aetna · Identified Aug 13, 2026Medium impact
Dostarlimab-gxly (Jemperli) (CPB 0993, reviewed 2026-01-27)
For commercial medical plan members, Aetna considers dostarlimab-gxly (Jemperli) medically necessary under its initial approval criteria for several mismatch repair deficient or microsatellite instability-high cancers, including endometrial, ampullary, breast, colorectal, esophageal, gastric, ovarian, pancreatic, small bowel and anal cancers. It also considers Jemperli in combination with pemetrexed and platinum chemotherapy for first-line metastatic nonsquamous non-small cell lung cancer without genomic aberrations. Members are not eligible when they have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy, and all other indications are considered experimental, investigational, or unproven.
Aetna · Identified Aug 12, 2026Medium impact
Optical Coherence Tomography and Microelastography for Solid Tumors and Other Selected Indications (CPB 0886, reviewed 2026-03-03)
Aetna considers optical coherence tomography and microelastography experimental, investigational, or unproven for the listed intra-operative uses because their effectiveness has not been established. These uses include assessment of lymph nodes or tumor margins in breast conserving surgery, differentiation of pancreatic neoplastic lesions, differentiation of normal and diseased thyroid and parathyroid tissues, and solid tumor surgery including optical biopsy of lymph nodes and real-time determination of surgical margins. The policy lists CPT codes and ICD-10 codes as not covered for the indications it names.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Intensity-Modulated Radiotherapy (IMRT): Central Nervous System Tumors
IMRT may be considered medically necessary for individuals with malignant or benign brain tumors when the tumor is proximate to organs at risk (brain stem, spinal cord, cochlea, and eye structures) and 3-dimensional conformal radiotherapy planning cannot meet dose-volume constraints for normal tissue tolerance. Hippocampal-avoiding IMRT may be considered medically necessary for individuals with brain tumor metastases outside a 5-mm margin around either hippocampus and expected survival of 4 months or more. IMRT is considered investigational for tumors of the central nervous system for all other indications.
Aetna · Identified Nov 5, 2026Low impact
Hematopoietic Cell Transplantation for Solid Tumors in Adults (CPB 0811, reviewed 2026-10-29)
Aetna's Clinical Policy Bulletin 0811 (last reviewed 2026-10-29) confirms that autologous and allogeneic hematopoietic cell transplantation for most adult solid tumors is considered experimental, investigational, or unproven and not covered, with listed CPT, HCPCS, and ICD-10 codes marked as not covered for those indications. The only exceptions are young adults with primitive neuroectodermal tumors, medulloblastoma, and Ewing sarcoma family tumors, which fall under CPB 0496 criteria. The source states no specific effective date for a change; the listed effective date (02/04/2011) is the original policy date and the next review is 09/09/2027.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code C72.0?

There are 20 tracked policy changes affecting code C72.0, including updates from Excellus BlueCross BlueShield, Health Net, Blue Cross Blue Shield of North Dakota. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code C72.0?

Payers that have issued tracked updates for code C72.0 include: Excellus BlueCross BlueShield, Health Net, Blue Cross Blue Shield of North Dakota, Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code C72.0 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C72.0. 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 C72.0?

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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Spine Procedures for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) Members - (Effective Date - 2027-01-01) 7.01.126

21-139 Medical Policies - 4th Quarter 2020

21-141 Medical Policies - 4th Quarter 2020

21-142 Medical Policies - 4th Quarter 2020

Lumbar Decompression - (Effective Date - 2026-10-15) 7.01.113

Pharmacy Policies Available Online

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy 6.01.12

Ziconotide (Prialt) (CPB 0712, reviewed 2026-10-14)

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

Brachytherapy (CPB 0371, reviewed 2026-05-20)

Ziconotide (Prialt) (CPB 0712, reviewed 2026-03-11)

Hematopoietic Cell Transplantation for Solid Tumors in Adults (CPB 0811, reviewed 2025-12-03)

Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors (CPB 0496, reviewed 2026-08-06)

Temozolomide (Temodar) Injection (CPB 0876, reviewed 2026-06-03)

Ribavirin for Inhalation Use (CPB 0155, reviewed 2026-04-21)

Plerixafor (CPB 0779, reviewed 2026-02-13)

Dostarlimab-gxly (Jemperli) (CPB 0993, reviewed 2026-01-27)

Optical Coherence Tomography and Microelastography for Solid Tumors and Other Selected Indications (CPB 0886, reviewed 2026-03-03)

Intensity-Modulated Radiotherapy (IMRT): Central Nervous System Tumors

Hematopoietic Cell Transplantation for Solid Tumors in Adults (CPB 0811, reviewed 2026-10-29)

What insurance policy changes affect code C72.0?

Which payers have updated policy for code C72.0?

How do I get notified when code C72.0 policy changes?

Why do payers change policies for code C72.0?