I11.0 Insurance Policy Changes

ICD-10 I11.0 is officially defined as "Hypertensive heart disease with heart failure." code I11.0 is referenced in 7 tracked payer policy changes from Florida Blue, Excellus BlueCross BlueShield, and 5 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code I11.0 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Florida Blue · Effective Jul 1, 2026High impact
Every Reading Counts: Your Contribution to Better Blood Pressure Outcomes
Florida Blue has issued updated guidance on blood pressure management documentation and coding for HEDIS reporting. Providers must now document exact blood pressure readings (no rounding or ranges), utilize specific CPT II codes (3074F-3080F) based on systolic/diastolic thresholds, and assign appropriate ICD-10 codes for hypertensive conditions. This change emphasizes detailed documentation to support quality measure compliance and care management targeting.
Excellus BlueCross BlueShield · Effective Mar 19, 2026Medium impact
Ventricular Assist Device (VAD) and Total Artificial Heart (TAH) 7.01.114
Excellus BlueCross BlueShield policy 7.01.114 covers ventricular assist devices (VADs) and total artificial hearts (TAH) for listed indications. FDA-approved VADs are considered medically appropriate as a bridge to transplant for individuals who meet all listed criteria, including approval as a heart transplant candidate by an approved heart transplant center, imminent risk of dying before donor heart procurement, optimal inotropic support, and an intra-aortic balloon pump unless contraindicated. VADs are also considered appropriate as a bridge to recovery and as destination therapy for adults who meet all listed criteria, such as NYHA Class III or IV heart failure, left ventricular ejection fraction of 25% or less, and inotrope dependence or a cardiac index below 2.2 liters/min/m2. Percutaneous VADs are considered medically necessary for listed indications, including high-risk PCI and short-term circulatory support in cardiogenic shock. A TAH is considered medically appropriate as a bridge to transplant, while a TAH as destination therapy is considered investigational.
Medicare/CMS - Transmittals · Effective Oct 28, 2025Medium impact
R13802CP: NCD 20.40- Renal Denervation (RDN) for Uncontrolled Hypertension
Medicare covers radiofrequency renal denervation and ultrasound renal denervation (collectively RDN) for uncontrolled hypertension under Coverage with Evidence Development, for dates of service on or after October 28, 2025. RDN for uncontrolled hypertension is not covered for patients outside of a CMS-approved study. Institutional and professional claims must carry specific ICD-10-PCS, CPT, HCPCS, ICD-10-CM, value code, condition code, modifier and place of service data.
Aetna · Identified Aug 14, 2026Medium impact
Intensive Cardiac Rehabilitation Programs (CPB 0267, reviewed 2026-05-14)
Aetna considers intensive cardiac rehabilitation programs (the Benson-Henry Institute Cardiac Wellness Program, the Ornish cardiac treatment program and the Pritikin Program) medically necessary as an alternative to traditional Phase II cardiac rehabilitation for members who meet the cardiac rehabilitation criteria, limited to 72 one-hour sessions, up to 6 per day, over a period of up to 18 weeks. Virtual delivery by real-time audio and video (excluding audio-only) is considered medically necessary when the telehealth program and member criteria are met, but hospital outpatient departments are not eligible for virtual telehealth services. Intensive cardiac rehabilitation is considered experimental, investigational or unproven for diabetes, hyperlipidemia, prostate cancer, metabolic syndrome and all other indications where effectiveness has not been established.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
Biventricular pacemakers with or without an implantable defibrillator may be considered medically necessary for heart failure in individuals with NYHA class III or IV symptoms, a left ventricular ejection fraction below 35%, sinus rhythm, guideline-directed medical therapy, and either left bundle branch block or a QRS interval of 150 ms or more. The same devices may also be considered medically necessary for NYHA class II heart failure with an ejection fraction of 30% or less and the same rhythm, therapy, and bundle branch block or QRS criteria, and for individuals with NYHA class I to IV heart failure, an ejection fraction of 50% or less, and atrioventricular block requiring a high percentage of ventricular pacing when they have an indication for a ventricular pacemaker, as an alternative to a right ventricular pacemaker. Biventricular pacing is considered investigational for NYHA class I heart failure and for heart failure with atrial fibrillation in individuals who do not meet these criteria, and triple-site cardiac resynchronization therapy, wireless left ventricular endocardial pacing, and an intrathoracic fluid monitoring sensor as a component of a biventricular pacemaker are considered investigational.
Medical Mutual of Ohio · Identified Jun 20, 2026Medium impact
HEDIS Advanced Illness and Frailty Exclusion
Medical Mutual of Ohio has implemented HEDIS exclusion guidelines for advanced illness and frailty patients. Billing teams must use specific ICD-10 codes to exclude eligible patients (ages 66-80 with both conditions, or 81+ with frailty) from certain HEDIS quality measures like cancer screenings and diabetes management.
Blue Cross of Idaho · Identified Jun 19, 2026Medium impact
One-to-One for Healthcare Professionals - Fall Edition
Blue Cross of Idaho scheduled the third phase of its claims processing system update for January 1, 2024, moving Individual and government lines, including Medicare Advantage, Medicare Supplement, MMCP and Idaho Medicaid Plus, to the Gemstone system, and Legacy will be sunset by the end of 2026. Effective October 1, 2023, bariatric surgery was changed to not medically necessary for individuals with a BMI less than 35 kg/m2 who do not have diabetes and for all individuals with a BMI less than 30 kg/m2. Effective October 1, 2023, the codes 33254, 33255, 33256, 33258, 33265 and 33266 were configured as Experimental/Investigational for an open or modified maze procedure performed on a non-beating heart during cardiopulmonary bypass without concomitant cardiac surgery.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code I11.0?

There are 7 tracked policy changes affecting code I11.0, including updates from Florida Blue, Excellus BlueCross BlueShield, Medicare/CMS - Transmittals. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code I11.0?

Payers that have issued tracked updates for code I11.0 include: Florida Blue, Excellus BlueCross BlueShield, Medicare/CMS - Transmittals, Aetna, Blue Cross & Blue Shield of Mississippi, Medical Mutual of Ohio, Blue Cross of Idaho.

How do I get notified when code I11.0 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code I11.0. 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 I11.0?

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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Every Reading Counts: Your Contribution to Better Blood Pressure Outcomes

Ventricular Assist Device (VAD) and Total Artificial Heart (TAH) 7.01.114

R13802CP: NCD 20.40- Renal Denervation (RDN) for Uncontrolled Hypertension

Intensive Cardiac Rehabilitation Programs (CPB 0267, reviewed 2026-05-14)

Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure

HEDIS Advanced Illness and Frailty Exclusion

One-to-One for Healthcare Professionals - Fall Edition

What insurance policy changes affect code I11.0?

Which payers have updated policy for code I11.0?

How do I get notified when code I11.0 policy changes?

Why do payers change policies for code I11.0?