F79 Insurance Policy Changes

ICD-10 F79 is officially defined as "Unspecified intellectual disabilities." code F79 is referenced in 7 tracked payer policy changes from Wisconsin Medicaid (ForwardHealth), New Jersey Medicaid, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code F79 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Wisconsin Medicaid (ForwardHealth) · Effective Oct 1, 2026Medium impact
ForwardHealth Covers Dental Case Management for Members With Special Health Care Needs
Beginning October 1, 2026, ForwardHealth covers dental case management for members with special health care needs, reimbursed under CDT code D9997 at $100 per visit. Prior authorization is required for more than one visit per member within 180 days, for D9997 billed with moderate to deep dental sedation in that period, for a member whose diagnosis is not a qualifying code but has documented medical necessity, and when the place of service is 15 (Mobile Unit). Prior authorization is not required for the first visit per member, per provider, every six months (180 days).
New Jersey Medicaid · Effective Oct 1, 2025Medium impact
Medicaid Alert MA-2025-03
New Jersey Medicaid is expanding the list of ICD-10-CM diagnosis codes that qualify for medical exception approval for outpatient dental services provided in a hospital operating room for beneficiaries with developmental disabilities and/or chronic medical conditions. This policy adds specific neurodevelopmental disorder codes (QA series) and clarifies which conditions meet the medical exception requirement. Prior authorization procedures and hospital reimbursement remain unchanged.
Indiana Medicaid (IHCP) · Effective Aug 1, 2025Medium impact
BT202598: IHCP announces changes to DRG grouper and inpatient hospital reimbursement rates
The IHCP selected the Solventum All-Patient Refined Diagnosis-Related Group (APR-DRG) grouper, version 42, for inpatient DRG assignments. This change is already effective for inpatient stays with discharge dates on or after Aug. 1, 2025. The DRG base rate for in-state hospitals will be $4,346, and the grouper version 36 remains in place for inpatient stays with discharge dates before Aug. 1, 2025.
Aetna · Identified Oct 23, 2026Medium impact
Ocular Photoscreening (CPB 0689, reviewed 2026-10-15)
Aetna Clinical Policy Bulletin 0689 considers ocular photo-screening medically necessary for screening pre-verbal children up to 5 years of age, and children or adolescents who are non-cooperative or non-verbal, such as those with intellectual disability, developmental delay, or severe behavioral disorders. CPT 99174 and 99177 are covered if selection criteria are met, while CPT 0469T is listed as not covered for the indications in the policy. Aetna considers retinal birefringence scanning for detecting eye misalignment or strabismus experimental, investigational, or unproven.
Aetna · Identified Aug 18, 2026Medium impact
Learning Disabilities, Dyslexia, and Vision (CPB 0078, reviewed 2026-03-18)
Aetna considers visual training and behavioral vision therapy for members with dyslexia or learning disabilities, ChromaGen lenses for improving learning skills in children with dyslexia, colored filtered or tinted lenses for dyslexia or learning disabilities, MoveR training, music-based interventions for individuals with learning disabilities, non-invasive brain stimulation including transcranial direct current stimulation for dyslexia, and pulsed lighting for dyslexia experimental, investigational or unproven because their effectiveness has not been established. There is no known eye or visual cause for dyslexia and learning disabilities and no effective visual treatment, and multidisciplinary evaluation and management must be based on proven procedures demonstrated by valid research. CPT codes 90867, 90868, 90869 and 92065, HCPCS codes A4541, E0733 and G0176, and the listed ICD-10 codes are not covered for the indications listed in the policy.
Aetna · Identified Aug 17, 2026Medium impact
Genetic Counseling (CPB 0189, reviewed 2026-03-27)
Aetna considers genetic counseling medically necessary for listed pregnancy-related indications, including couples who are closely related genetically, familial cancer disorders, pregnant women with maternal age 35 years or greater at delivery, and parents of a child born with a genetic disorder or birth defect. Genetic counseling unrelated to pregnancy is covered when it is appropriate for, or provided with, medically necessary genetic testing in accordance with ACMG guidelines. Genetic counseling for all other indications is considered experimental, investigational or unproven.
Aetna · Identified Aug 13, 2026Medium impact
Pediatric Intensive Feeding Programs (CPB 0809, reviewed 2025-12-11)
Aetna considers professional services for pediatric intensive feeding programs medically necessary for infants and children with complex feeding and swallowing disorders when an interdisciplinary team provides the care and every listed condition is met. Those conditions include behavior problems interfering with feeding, a documented diagnosis-specific treatment plan with estimated length of treatment, medical causes of failure to thrive treated without resolving the feeding problem, physician coordination and oversight, one of the listed feeding problems, and no response to initial treatment by a single discipline over a 2-month period. Other indications, such as childhood obesity and Prader-Willi syndrome, are considered experimental, investigational, or unproven, and electrical stimulation for swallowing or feeding disorders is also considered experimental, investigational, or unproven.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code F79?

There are 7 tracked policy changes affecting code F79, including updates from Wisconsin Medicaid (ForwardHealth), New Jersey Medicaid, Indiana Medicaid (IHCP). Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code F79?

Payers that have issued tracked updates for code F79 include: Wisconsin Medicaid (ForwardHealth), New Jersey Medicaid, Indiana Medicaid (IHCP), Aetna.

How do I get notified when code F79 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code F79. 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 F79?

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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ForwardHealth Covers Dental Case Management for Members With Special Health Care Needs

Medicaid Alert MA-2025-03

BT202598: IHCP announces changes to DRG grouper and inpatient hospital reimbursement rates

Ocular Photoscreening (CPB 0689, reviewed 2026-10-15)

Learning Disabilities, Dyslexia, and Vision (CPB 0078, reviewed 2026-03-18)

Genetic Counseling (CPB 0189, reviewed 2026-03-27)

Pediatric Intensive Feeding Programs (CPB 0809, reviewed 2025-12-11)

What insurance policy changes affect code F79?

Which payers have updated policy for code F79?

How do I get notified when code F79 policy changes?

Why do payers change policies for code F79?