E79.0 Insurance Policy Changes

ICD-10 E79.0 is officially defined as "Hyperuricemia without signs of inflammatory arthritis and tophaceous disease." code E79.0 is referenced in 4 tracked payer policy changes from Excellus BlueCross BlueShield and Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code E79.0 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, 2026High impact
Continuous Glucose Monitoring Systems/External Insulin Pump Therapy for Diabetes 1.01.30
Excellus BlueCross BlueShield medical policy 1.01.30 expanded its criteria for insulin pump requests to include members who use continuous glucose monitoring rather than finger sticks. The December 18, 2025 annual review removed insulin dependency requirements and states that disposable external insulin pumps are no longer investigational. The May 22, 2025 update had changed the initial pump self-testing requirement from four times a day to three times per day, and the prior initiation requirement from two months to one month.
Aetna · Effective Jan 1, 2026Medium impact
Gout (CPB 0810, reviewed 2026-03-27)
Aetna's Clinical Policy Bulletin 0810 for gout applies to commercial medical plans and was last reviewed 03/27/2026. Pegloticase (Krystexxa) is covered for chronic gout in members 18 or older who meet the initial approval criteria, and for continuing therapy when the continuation criteria are met. Oral urate-lowering therapy cannot be used at the same time as pegloticase. The Site of Care Utilization Management Policy applies to pegloticase beginning January 1, 2026. Pegloticase is considered experimental, investigational, or unproven for all other indications, including asymptomatic hyperuricemia and G6PD deficiency. Blood uric acid measurement, erythrocyte sedimentation rate, polarized light microscopy of synovial fluid, and MRI for gouty tophus are considered medically necessary for managing gout.
Aetna · Identified Sep 30, 2026Medium impact
Pancreas Transplantation Alone (PTA) and Islet Cell Transplantation (CPB 0601, reviewed 2026-09-18)
Aetna's Clinical Policy Bulletin 0601 covers pancreas transplantation alone (PTA) and islet cell transplantation for commercial medical plans, and precertification of Lantidra (donislecel-jujn) is required in applicable plan designs. PTA is medically necessary for members who meet the transplanting institution's selection criteria, or, absent those criteria, the general criteria (controlled HIV with CD4 count greater than 200 cells/mm3 for more than 6 months and undetectable viral load, creatinine clearance greater than 40 ml/min, ejection fraction greater than or equal to 40%, and no malignancy except non-melanomatous skin cancers or low-grade prostate cancer) and the disease criteria (labile insulin-dependent diabetes with recurrent, acute and severe metabolic complications, and consistent failure of insulin-based management shown by HbA1c greater than 8.0 despite aggressive conventional therapy). Islet cell allotransplantation with Lantidra is covered for members 18 years or older with type 1 diabetes who cannot approach target HbA1c because of repeated severe hypoglycemia despite intensive diabetes management, when it is used with concomitant immunosuppression, the member has not had a renal transplant, and no more than 3 infusions have been given, while PTA for increased longevity, PTA primarily for lifestyle reasons, ex-situ machine pancreas perfusion, and pancreatic islet xenotransplantation are considered experimental, investigational, or unproven.
Aetna · Identified Aug 13, 2026Medium impact
Pancreas Transplantation Alone (PTA) and Islet Cell Transplantation (CPB 0601, reviewed 2025-09-10)
Aetna considers pancreas transplantation alone (PTA) without a kidney transplant medically necessary for members who meet the transplanting institution's selection criteria. Where there are no institution criteria, PTA is considered medically necessary when general criteria are met, including controlled HIV with CD4 count greater than 200 cells/mm3 for more than 6 months and undetectable HIV-1 RNA, ejection fraction greater than or equal to 40%, and creatinine clearance greater than 40 ml/min, and disease-specific criteria are met, including labile insulin-dependent diabetes with recurrent severe metabolic complications and consistent failure of insulin-based management with HbA1c greater than 8.0. Islet cell allotransplantation with donislecel-jujn (Lantidra) is considered medically necessary when its initial approval criteria are met, and precertification of Lantidra is required of all Aetna participating providers and members in applicable plan designs.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code E79.0?

There are 4 tracked policy changes affecting code E79.0, including updates from Excellus BlueCross BlueShield, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code E79.0?

Payers that have issued tracked updates for code E79.0 include: Excellus BlueCross BlueShield, Aetna.

How do I get notified when code E79.0 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code E79.0. 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 E79.0?

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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Continuous Glucose Monitoring Systems/External Insulin Pump Therapy for Diabetes 1.01.30

Gout (CPB 0810, reviewed 2026-03-27)

Pancreas Transplantation Alone (PTA) and Islet Cell Transplantation (CPB 0601, reviewed 2026-09-18)

Pancreas Transplantation Alone (PTA) and Islet Cell Transplantation (CPB 0601, reviewed 2025-09-10)

What insurance policy changes affect code E79.0?

Which payers have updated policy for code E79.0?

How do I get notified when code E79.0 policy changes?

Why do payers change policies for code E79.0?