ICD-10 E78.019 is officially defined as "Familial hypercholesterolemia, unspecified." code E78.019 is referenced in 8 tracked payer policy changes from Blue Cross Blue Shield of Rhode Island, Blue Cross Blue Shield of North Dakota, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code E78.019 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Multiple policy updates are rolling out between February-April 2026, including InterQual criteria changes for molecular diagnostics and procedures, fertility coverage modifications, removal of prior authorization for several genetic testing and continuous glucose monitoring codes, and updated diagnosis code lists for various services.
The following medical policies take effect Jan. 1, 2026: new policies for Aqueous Shunts and Stents for Glaucoma, Computerized Corneal Topography, Renal Denervation System, Skin Substitutes, Supplementary Algorithm for Cardiac Magnetic Resonance Imaging, and Fibrin Sealant, along with revised policies including Patient Lifts, Biofeedback, Intensity-Modulated Radiotherapy, and Electrical Nerve Stimulation. Coding changes effective Oct. 1, 2025 added new codes E0150, A9288, L1007, and A9616 for their listed services, and many policies removed G35 from covered diagnosis codes and added G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35.C2, and G35.D. Cervical Fusions, Corneal Topography, Amniotic Membrane and Amniotic Fluid, and Bioengineered Skin and Soft Tissue Substitutes policies will be archived or retired.
Independence Administrators updated CAC testing policy to clarify that coronary artery calcium testing is medically necessary if it has not been performed within the preceding 5 years in eligible low-risk individuals. The policy effective 09/19/2026 specifies strict clinical criteria for coverage, including age 40-75, LDL 70-190 mg/dL, 10-year ASCVD risk 5-20%, and absence of multiple exclusionary conditions. All other uses remain experimental/investigational and non-covered.
Blue Cross Blue Shield of North Dakota revised many Commercial prior authorization medical drug policies, with revisions effective May 12, 2026. Changes include new indications such as Darzalex SQ for newly diagnosed multiple myeloma, Keytruda IV and SQ for platinum-resistant ovarian cancer, and management of CAR T-cell and lymphocyte engager-related toxicities for several drugs, along with length of authorization updates, new ICD-10 codes and HCPCS code changes.
LDL apheresis may be considered medically necessary for homozygous familial hypercholesterolemia as an alternative to plasmapheresis. It may also be considered medically necessary for heterozygous familial hypercholesterolemia after failed diet therapy and maximum tolerated combination drug therapy, when the FDA-approved indications are met, such as functional heterozygotes with LDL of 300 mg/dL or higher, or LDL of 200 mg/dL or higher with documented coronary artery disease. LDL apheresis is considered investigational for other uses, and therapeutic apheresis with selective HDL delipidation and plasma reinfusion is considered investigational for all indications. A 10/01/2025 code update added ICD-10 codes E78.010, E78.011, and E78.019.
Independence Administrators updated policy 09.00.58a effective 10/01/2025 to replace the generic ICD-10 code E78.01 (Familial hypercholesterolemia) with three more specific codes: E78.010 (Homozygous), E78.011 (Heterozygous), and E78.019 (Unspecified). Billing teams must update their systems to use the new granular diagnosis codes when submitting CAC testing claims for familial hypercholesterolemia cases.
Aetna covers inclisiran (Leqvio) for commercial medical plans, and precertification is required for members in applicable plan designs. Coverage depends on the prescriber being a cardiologist, endocrinologist, lipid specialist, or a prescriber specialized in the treatment of hypercholesterolemia, plus the member's ASCVD history, current LDL-C level, and statin therapy or statin intolerance. The recommended dose is 284 mg by subcutaneous injection initially, again at 3 months, and then every 6 months.
Aetna considers automated ambulatory blood pressure monitoring medically necessary when a member meets one of the listed criteria: at least two elevated office readings taken on separate days to identify 'white coat' hypertension; episodic hypertension with symptoms suggesting an adrenal tumor and repeatedly normal office readings; hypotensive symptoms or syncope thought related to antihypertensive medications; syncope evaluated with a 24-hour Holter monitor; nocturnal angina; resistant hypertension before an invasive investigation for secondary causes; or autosomal dominant polycystic kidney disease in children and young adults 30 years of age or younger. Monitoring for less than 24 hours or more than 3 days is not considered medically necessary, and repeat testing is not generally necessary more often than every 6 months. Aetna considers the use experimental, investigational, or unproven for heart failure, for pregnant women who do not meet the criteria, for diagnosing malignant hypertension, for members with an irregular cardiac rhythm such as atrial fibrillation, for routine monitoring to establish a hypertension diagnosis or evaluate treatment response, and for routine use before continuous positive airway pressure (CPAP) therapy.
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