D40.0 Insurance Policy Changes

ICD-10 D40.0 is officially defined as "Neoplasm of uncertain behavior of prostate." code D40.0 is referenced in 14 tracked payer policy changes from Excellus BlueCross BlueShield, Blue Cross & Blue Shield of Mississippi, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code D40.0 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 Oct 15, 2026High impact
Magnetic Resonance Imaging (MRI) of the Prostate - (Effective Date - 2026-10-15) 6.01.46
MRI of the pelvis is considered medically appropriate for men with suspected prostate cancer who meet one of the listed indications, including men aged 40 to 75 with a PSA greater than 3 ng/ml or a very suspicious digital rectal exam plus a listed high-risk feature, men aged 45 to 75 with a PSA greater than 3 ng/ml or a very suspicious digital rectal exam, and men older than 75 with a PSA of 4 ng/ml or greater or a very suspicious digital rectal exam. A 06/18/26 update removed very low risk from the NCCN initial risk stratification criteria, added new criteria for suspected prostate cancer and for restaging, removed criteria for non-metastatic prostate cancer previously treated with prostatectomy, radiation therapy, ablation hormonal therapy or chemotherapy where PSA does not fall after prostatectomy, and removed the salvage local therapy criteria. Serial MRIs are considered not medically necessary when monitoring an elevated PSA for suspected prostate cancer, and MR guidance for needle placement is not medically necessary for prostate biopsy.
Excellus BlueCross BlueShield · Effective Sep 17, 2026Medium impact
Radiopharmaceuticals for the Treatment of Cancer 6.01.44
This medical policy sets when radiopharmaceutical cancer treatments are considered medically appropriate: Xofigo for castration-resistant prostate cancer with symptomatic bone metastases, Pluvicto for PSMA-positive metastatic castration-resistant prostate cancer, Lutathera for somatostatin receptor-positive neuroendocrine tumors, strontium-89 chloride for bone pain from confirmed skeletal metastases, and HICON for thyroid carcinoma. Treatment regimens beyond the U.S. Food and Drug Administration approved regimen are considered investigational. The current version is effective September 17, 2026, with an annual review, and the policy intent is unchanged.
Excellus BlueCross BlueShield · Effective Sep 17, 2026Medium impact
Radiopharmaceuticals for the Treatment of Cancer 6.01.44
Policy 6.01.44 considers radiopharmaceutical treatments for cancer medically appropriate only within their FDA-approved regimen, and requests in excess of that regimen are considered investigational. Xofigo is considered medically appropriate for castration-resistant prostate cancer with symptomatic bone metastases and no known visceral metastatic disease or bulky regional lymph nodes greater than 3 cm on imaging within the past 30 days. Pluvicto, Lutathera, strontium-89 chloride, and HICON (sodium iodide I 131) are each considered medically appropriate only when their listed criteria are met. The September 18, 2025 review added a new Pluvicto indication and removed Azedra and Zevalin because both are no longer commercially available.
Excellus BlueCross BlueShield · Effective Sep 17, 2026Medium impact
Laboratory Testing for the Screening and Management of Prostate Cancer 2.02.48
Excellus BlueCross BlueShield policy 2.02.48 considers biomarker tests for prostate cancer that diagnose or determine a risk score investigational, including PROGENSA PCA3, 4Kscore, Prostate Health Index and ConfirmMDx. Gene expression analysis to guide management of prostate cancer is considered medically appropriate only under the listed criteria, and ArteraAI is considered investigational for management of prostate cancer. The current version is effective September 17, 2026, and its most recent change is an annual review with the policy intent unchanged.
Excellus BlueCross BlueShield · Effective Apr 16, 2026Medium impact
Germline Genetic Testing for Hereditary Cancers 2.02.60
Excellus BlueCross BlueShield policy 2.02.60 considers germline genetic testing for hereditary cancer medically appropriate in listed circumstances, including when a blood relative has a known pathogenic or likely pathogenic variant, when a pathogenic or likely pathogenic variant is found on tumor genomic testing, when results aid systemic therapy or surgical decisions, and when individuals meet specific criteria for breast, ovarian, pancreatic, prostate, colorectal, Cowden syndrome, Li-Fraumeni syndrome, hereditary diffuse gastric cancer or familial medullary thyroid carcinoma. Multigene panel testing is considered medically appropriate when an individual meets Policy Statement I, except Policy Statements I.A, I.D and I.G.9. The current effective date is April 16, 2026, and the annual update kept the policy intent unchanged.
Excellus BlueCross BlueShield · Effective Feb 19, 2026Medium impact
Molecular Testing of Tumor Tissue to Identify Targeted Therapies for Cancers 2.02.51
Excellus BlueCross BlueShield policy 2.02.51 considers molecular testing of tumor tissue medically appropriate to direct targeted therapy when the results will guide patient management and the test is for the listed cancers and genes, including metastatic colorectal cancer, non-small-cell lung cancer, stage III high-risk or stage IV melanoma, metastatic pancreatic cancer, recently diagnosed or recurrent ovarian cancer, metastatic prostate cancer, breast cancer, primary brain tumors, ependymomas, and medulloblastoma. For other cancers, testing must be recommended by current NCCN guidelines, include only the number of genes necessary for therapeutic decision making, and be used for biopsy-confirmed advanced stage III or IV or metastatic disease, or for such disease progressing after chemotherapy or immunotherapy when never previously tested. Comprehensive genomic profiling tests such as FoundationOne CDx are considered investigational, as is testing for genes other than those listed, and the version effective February 19, 2026 is an annual review with policy intent unchanged.
Excellus BlueCross BlueShield · Effective Feb 19, 2026Medium impact
Circulating Tumor DNA for Management of Cancer (Liquid Biopsy) 2.02.56
Excellus policy 2.02.56 Circulating Tumor DNA for Management of Cancer (Liquid Biopsy) has a current effective date of February 19, 2026, and its 02/19/26 annual review states that policy intent is unchanged. Circulating tumor DNA analysis is considered medically appropriate only when it is used to direct targeted therapy, as an alternative to tissue biopsy when repeat invasive biopsy is contraindicated or there is not enough tissue, when the results will guide management, and when the test has FDA approval for the tumor type or disease site, and only for the listed cancers and gene targets. Liquid biopsy is investigational for all other indications, and comprehensive genomic profiling tests such as FoundationOne Liquid CDx and Guardant 360 are considered investigational.
Blue Cross & Blue Shield of Mississippi · Effective Jan 1, 2026Medium impact
Magnetic Resonance Imaging-Targeted Biopsy of the Prostate
BCBSMS policy L.7.01.448 states that magnetic resonance imaging-targeted biopsy of the prostate may be considered medically necessary for diagnosis and active surveillance of prostate cancer. Effective 01/01/2026, the Code Reference section adds new CPT codes 55708, 55710, 55711, 55712, 55713, 55714 and 55715 for MRI-fusion and in-bore CT- or MRI-guided prostate biopsy.
Aetna · Identified Oct 1, 2026Medium impact
Prostate Cancer Screening (CPB 0521, reviewed 2026-08-28)
Aetna's Clinical Policy Bulletin 0521 covers prostate cancer screening. PSA screening is medically necessary as a preventive service for average-risk men 45 years of age and older, and for high-risk men 40 years of age and older, including African-American men and men with a family history of prostate cancer. Routine screening for members 75 years of age or older is not medically necessary unless life expectancy is 10 years or more, and tests such as Stockholm3, the Apifiny non-PSA blood test and the EpiSwitch Prostate Screening Test are considered experimental, investigational or unproven for prostate cancer screening.
Aetna · Identified Aug 14, 2026Medium impact
Transrectal Ultrasound (CPB 0001, reviewed 2026-03-05)
Aetna considers transrectal ultrasound (TRUS) medically necessary for specific conditions involving the prostate, rectum and surrounding tissues. These include clinical staging of prostate cancer and rectal carcinoma, determining prostate volume before brachytherapy, evaluation of anal or rectal fistula and peri-rectal abscesses, evaluation of hematospermia, assessment of anal sphincter dysfunction, evaluation of benign or malignant peri-rectal tumors, and infertility or azoospermia where an ejaculatory duct cyst is suspected. Metastatic lesions of unknown source with a PSA greater than 10 ng/ml that could originate in the prostate are also covered. TRUS as a screening test for prostate disease, TRUS elastography for evaluation of prostate cancer, and TRUS for cervical cancer are listed as experimental, investigational or unproven. Last review date is 03/05/2026 and next review is 01/14/2027.
Aetna · Identified Aug 14, 2026Medium impact
Magnetic Resonance Spectroscopy (MRS) (CPB 0202, reviewed 2026-03-26)
Magnetic resonance spectroscopy (MRS) is considered medically necessary for specific indications in this policy, including assessing prognosis in hypoxic ischemic encephalopathy, distinguishing low grade from high grade gliomas, and distinguishing recurrent brain tumor from radiation-induced tumor necrosis. MRS is considered experimental, investigational, or unproven for all other indications listed, including breast cancer, prostate cancer, epilepsy, dementia and movement disorders, and traumatic brain injury. CPT 76390 is covered for the listed indications, and CPT codes 0609T, 0610T, 0611T and 0612T are not covered for the indications listed. The policy was last reviewed 03/26/2026.
Aetna · Identified Aug 14, 2026Medium impact
Prostate Cancer Screening (CPB 0521, reviewed 2025-11-25)
Aetna considers PSA screening medically necessary as a preventive service for men 45 years of age and older who are average risk and men 40 years of age and older who are high risk, including African-American men and men with a family history of prostate cancer. Routine prostate cancer screening for members 75 years of age or older is considered not medically necessary unless life expectancy is greater than or equal to 10 years, and annual digital rectal examination (DRE) is covered as a service. Several blood, urine and tissue tests, including PCA3, Stockholm3, ProstateNext, the four-kallikrein panel and selenium measurement, are considered experimental, investigational, or unproven for prostate cancer screening, and the CPT codes listed as not covered apply to the indications in the policy.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Immunohistochemistry for Microscopic Evaluation of Prostate Biopsy
IHC stains may be considered medically necessary in diagnosing prostate cancer when H&E stains are suspicious but not diagnostic, when the primary site of origin is uncertain, or when the tumor type is in the microscopic differential diagnosis. Listed indications include an indeterminate or suspicious focus with no other positive cores, a single worrisome core, a worrisome core contralateral to a positive core, and specified multi-part biopsy combinations with Gleason grades and atypical small acinar proliferation. IHC testing on morphologically negative cores is considered not medically necessary, as is IHC on a negative or suspicious core when obvious prostate cancer is present in other cores, unless the additional diagnosis changes the patient's stage or treatment, and IHC stains performed as reflex templates or pre-orders before the pathologist reviews the H&E stain.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer
Saturation biopsy of the prostate, taking 20 or more core tissue samples at one time, is considered medically necessary in the diagnosis, staging, and management of prostate cancer. For Federal Employee Program (FEP) subscribers, the same procedure is considered investigational. The policy history records a 09/11/2025 review with no changes to the policy statement.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code D40.0?

There are 14 tracked policy changes affecting code D40.0, including updates from Excellus BlueCross BlueShield, Blue Cross & Blue Shield of Mississippi, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code D40.0?

Payers that have issued tracked updates for code D40.0 include: Excellus BlueCross BlueShield, Blue Cross & Blue Shield of Mississippi, Aetna.

How do I get notified when code D40.0 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code D40.0. 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 D40.0?

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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Magnetic Resonance Imaging (MRI) of the Prostate - (Effective Date - 2026-10-15) 6.01.46

Radiopharmaceuticals for the Treatment of Cancer 6.01.44

Radiopharmaceuticals for the Treatment of Cancer 6.01.44

Laboratory Testing for the Screening and Management of Prostate Cancer 2.02.48

Germline Genetic Testing for Hereditary Cancers 2.02.60

Molecular Testing of Tumor Tissue to Identify Targeted Therapies for Cancers 2.02.51

Circulating Tumor DNA for Management of Cancer (Liquid Biopsy) 2.02.56

Magnetic Resonance Imaging-Targeted Biopsy of the Prostate

Prostate Cancer Screening (CPB 0521, reviewed 2026-08-28)

Transrectal Ultrasound (CPB 0001, reviewed 2026-03-05)

Magnetic Resonance Spectroscopy (MRS) (CPB 0202, reviewed 2026-03-26)

Prostate Cancer Screening (CPB 0521, reviewed 2025-11-25)

Immunohistochemistry for Microscopic Evaluation of Prostate Biopsy

Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer

What insurance policy changes affect code D40.0?

Which payers have updated policy for code D40.0?

How do I get notified when code D40.0 policy changes?

Why do payers change policies for code D40.0?