I13.11 Insurance Policy Changes

ICD-10 I13.11 is officially defined as "Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease." code I13.11 is referenced in 7 tracked payer policy changes from Horizon BCBS NJ, Capital Blue Cross, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code I13.11 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Horizon BCBS NJ · Effective Jan 1, 2026High impact
Statin Use in Persons with Diabetes (SUPD)
This is a new Medicare Part D Star Ratings measure (SUPD) effective for 2026 that evaluates whether patients ages 40-75 with diabetes on antidiabetic medications are also receiving statin therapy. Billing teams must ensure proper documentation and ICD-10 coding of exclusionary diagnoses to accurately track eligible patients and avoid measure performance penalties. Claims must include appropriate exclusion codes when patients have contraindications to statin therapy.
Capital Blue Cross · Effective Apr 1, 2026Medium impact
AB2026-04-002 Medicare only
Capital Blue Cross updated Medicare Part D Star measures for 2026, adding new exclusions for Statin Use in Persons with Diabetes (SUPD) that recognize PCSK9 inhibitors and bempedoic acid as alternatives for patients who cannot tolerate statins. Providers must submit specific ICD-10-CM codes annually during in-person or audio/video visits to qualify patients for exclusions from the SUPD measure.
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 Oct 2, 2026Medium impact
Cardiovascular Monitoring Equipment for Home Use: Pulse, Blood Pressure, Telemonitors, and Pacemaker Monitors (CPB 0548, reviewed 2026-08-21)
Aetna considers validated home blood pressure monitors medically necessary as an alternative to ambulatory blood pressure monitoring to confirm hypertension in members age 18 and older with office readings greater than 140 systolic or 90 diastolic. Validated blood pressure monitors are considered medically necessary for members receiving hemodialysis or peritoneal dialysis in the home, and validated blood pressure cuffs are considered medically necessary durable medical equipment for members with hypertension. Self-contained pacemaker monitors, including audible and visible signal monitors, digital electronic monitors, and a specialized telephone attachment for trans-telephonic transmission of results, are considered medically necessary for members with cardiac pacemakers. Automated oscillometer serial blood pressure monitors for home use, AngelMed Guardian, CardioMEMS pillow and components, home and implantable congestive heart failure monitors, implantable inferior vena cava sensors, implantable wireless pulmonary artery pressure monitors for heart failure, Zoll Heart Failure and Arrhythmia Management System, bioelectrical impedance analysis, and non-invasive central blood pressure assessment with SphygmoCor are considered experimental, investigational, or unproven. Pulse tachometers do not meet Aetna's definition of covered durable medical equipment.
Aetna · Identified Aug 15, 2026Medium impact
Cardiovascular Monitoring Equipment for Home Use: Pulse, Blood Pressure, Telemonitors, and Pacemaker Monitors (CPB 0548, reviewed 2025-08-22)
Aetna considers validated home blood pressure monitors medically necessary as an alternative to ambulatory blood pressure monitoring to confirm hypertension in members age 18 and older with office readings greater than 140 systolic or 90 diastolic, when the cuff is prescribed by a physician, is an arm device, has the correct cuff size assessed and provided by the vendor, and only one cuff per 5 years is considered medically necessary. Validated blood pressure monitors are also considered medically necessary for members receiving hemodialysis or peritoneal dialysis in the home, and self-contained pacemaker monitors are considered medically necessary for members with cardiac pacemakers. Pulse tachometers do not meet Aetna's definition of covered DME, and the following are considered experimental, investigational, or unproven: AngelMed Guardian, automated oscillometer serial blood pressure monitors for home use, bioelectrical impedance analysis, CardioMEMS, home congestive heart failure telemonitoring devices, implantable congestive heart failure monitors, the implantable inferior vena cava sensor, non-invasive central blood pressure assessment with the SphygmoCor System, and the Zoll Heart Failure and Arrhythmia Management System for monitoring pulmonary fluid levels. The bulletin is titled CPB 0548, reviewed 2025-08-22, with a last review of 08/21/2026.
Presbyterian Health Plan · Identified Jul 31, 2026Medium impact
2026 July Network Connection
CPT 90785 (interactive complexity) may be billed only as an add-on code that accompanies an eligible primary psychiatric service, and only when its specific criteria and requirements are met. Medical records must clearly support CPT 90785 by describing specific communication challenges, challenges affecting clinical interaction, the interactive methods used, and why standard communication approaches were insufficient, and claims submitted without adequate documentation may be subject to audit or review with payment adjusted if billing requirements are not met. Nail pathogen panel claims should be supported by clear clinical indication and medical necessity, prior testing and treatment history, a valid signed provider order specifying test type, and accurate diagnosis coding, and the Presbyterian Program Integrity Department performs random claims validation audits.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Continuous Arteriovenous Hemofiltration
Continuous renal replacement therapy may be considered medically necessary as supportive treatment for acute renal failure. CPT 90945 and 90947 cover dialysis procedures other than hemodialysis, including hemofiltration and other continuous renal replacement therapies. The policy was reviewed on 01/14/2026 with its policy statement unchanged, and ICD-9 diagnosis codes were removed from the code reference.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code I13.11?

There are 7 tracked policy changes affecting code I13.11, including updates from Horizon BCBS NJ, Capital Blue Cross, Medicare/CMS - Transmittals. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code I13.11?

Payers that have issued tracked updates for code I13.11 include: Horizon BCBS NJ, Capital Blue Cross, Medicare/CMS - Transmittals, Aetna, Presbyterian Health Plan, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code I13.11 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code I13.11. 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 I13.11?

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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Statin Use in Persons with Diabetes (SUPD)

AB2026-04-002 Medicare only

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

Cardiovascular Monitoring Equipment for Home Use: Pulse, Blood Pressure, Telemonitors, and Pacemaker Monitors (CPB 0548, reviewed 2026-08-21)

Cardiovascular Monitoring Equipment for Home Use: Pulse, Blood Pressure, Telemonitors, and Pacemaker Monitors (CPB 0548, reviewed 2025-08-22)

2026 July Network Connection

Continuous Arteriovenous Hemofiltration

What insurance policy changes affect code I13.11?

Which payers have updated policy for code I13.11?

How do I get notified when code I13.11 policy changes?

Why do payers change policies for code I13.11?