Does AmeriHealth Caritas require prior authorization for J1094?

AmeriHealth Caritas lists J1094 on AmeriHealth Caritas Louisiana prior authorization service list for medicaid managed plans. Verify with the payer before scheduling.

Does CalViva Health require prior authorization for J1094?

CalViva Health lists J1094 on CalViva Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Centene require prior authorization for J1094?

Centene lists J1094 on Sunshine Health Title XIX, Title XXI, Managed Medical Assistance CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Community Health Plan of Imperial Valley require prior authorization for J1094?

Community Health Plan of Imperial Valley lists J1094 on Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

What insurance policy changes affect HCPCS J1094?

There are 7 tracked policy changes affecting HCPCS J1094, including updates from Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for HCPCS J1094?

Payers that have issued tracked updates for HCPCS J1094 include: Aetna.

How do I get notified when HCPCS J1094 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to HCPCS J1094. 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 HCPCS J1094?

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.

PAYER POLICY CHANGES

J1094 Insurance Policy Changes

HCPCS J1094 is officially defined as "Injection, dexamethasone acetate, 1 mg." HCPCS J1094 is referenced in 7 tracked payer policy changes from Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS J1094 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Aetna · Identified Oct 26, 2026Medium impact
Guillain-Barre Syndrome Treatments (CPB 0732, reviewed 2026-10-21)
Aetna's Clinical Policy Bulletin 0732 (last reviewed 10/21/2026) considers intravenous immunoglobulin (IVIG), outpatient pulmonary rehabilitation and plasmapheresis medically necessary for Guillain-Barre syndrome when the criteria in their own policies are met. It lists other therapies as experimental, investigational or unproven for this indication, including corticosteroids, eculizumab, interferons, rituximab, sugammadex and acupuncture. The source does not describe what changed in this review.
Aetna · Identified Aug 15, 2026Medium impact
Remestemcel-L-rknd (Ryoncil) (CPB 1077, reviewed 2026-05-27)
For commercial medical plans, Aetna considers remestemcel-L-rknd (Ryoncil) medically necessary for steroid-refractory acute graft-versus-host disease (aGVHD) in pediatric members, up to a maximum of 8 infusions, when the disease progressed within 3 days or did not improve within 7 consecutive days of treatment with methylprednisolone 2 mg/kg/day or equivalent. Precertification is required of all Aetna participating providers and members in applicable plan designs. Continuation is considered medically necessary for a partial or mixed response (maximum of 4 infusions) or for a recurrence after complete response (maximum of 8 infusions), and all other indications are experimental, investigational, or unproven.
Aetna · Identified Aug 15, 2026Medium impact
Guillain-Barre Syndrome Treatments (CPB 0732, reviewed 2025-12-19)
Aetna considers IVIG medically necessary for Guillain-Barre syndrome (GBS) when the criteria in CPB 0206 are met, plasmapheresis when the criteria in CPB 0285 are met, and an outpatient pulmonary rehabilitation program when the criteria in CPB 0032 are met. Aetna considers acupuncture, amantadine, corticosteroids, eculizumab, interferons, leukocyte trafficking inhibitors, rituximab, sugammadex, Bifidobacterium infantis and several other therapies for GBS experimental, investigational, or unproven because their effectiveness for this indication has not been established. Codes covered when selection criteria are met include CPT 36514 and 90283, HCPCS J1561, J1566, J1568, J1569 and S9473, and ICD-10 G61.0.
Aetna · Identified Aug 15, 2026Medium impact
Carbon Dioxide Laser (CPB 0427, reviewed 2026-07-08)
Aetna's clinical policy bulletin for carbon dioxide laser (CPB 0427) lists the uses it considers medically necessary: condyloma, pelvic pain associated with endometriosis, primary penile tumors (clinical stage Tis, Ta, and T1 Grade 1 to 2), refractory plantar warts, removal of actinic keratoses for members who meet CPB 0567 criteria, removal of superficial basal cell carcinomas, and fractional carbon dioxide laser for hypertrophic burn, traumatic, and surgical scars when conventional therapies have failed. Aetna considers carbon dioxide laser experimental, investigational, or unproven for a list of other indications, including hidradenitis suppurativa, male androgenetic alopecia, onychomycosis, port wine stains, stress urinary incontinence, and vaginal atrophy. Aetna considers carbon dioxide laser treatment of other actinic lesions cosmetic.
Aetna · Identified Aug 14, 2026Medium impact
Eagle's and Ernest Syndrome (CPB 0400, reviewed 2026-06-30)
Aetna's Clinical Policy Bulletin 0400 considers styloidectomy medically necessary for Eagle's syndrome only when specific criteria are met, with separate criteria for the non-vascular form and the vascular form linked to carotid artery dissection. Radiofrequency thermoneurolysis is considered experimental, investigational or unproven for Eagle's and Ernest syndromes, and styloidectomy for jugular vein stenosis, for carotid stenosis without dissection, and for other listed indications such as tinnitus, headache and neck pain is also considered experimental, investigational or unproven.
Aetna · Identified Oct 3, 2026Low impact
Hammertoe Repair (CPB 0636, reviewed 2026-09-11)
Aetna's Clinical Policy Bulletin 0636 sets out the criteria it uses to consider hammertoe repair medically necessary, including radiographs, proof of skeletal maturity, and at least 3 months of documented conservative treatment with persistent pain and difficulty walking, plus one of the listed indications. It treats the named fixation implants, plantar plate repair, and hammertoe repair that does not meet the criteria as experimental. The source shows a review date of 2026-09-11 but states no effective date, so treat it as historical material and confirm current applicability.
Aetna · Identified Aug 16, 2026Low impact
Hammertoe Repair (CPB 0636, reviewed 2025-12-11)
This is Aetna's Clinical Policy Bulletin 0636 on hammertoe repair, reviewed 2025-12-11, so it is historical material from an older source. It considers surgical repair medically necessary for members who are skeletally mature or 18 or older when radiographic confirmation, persistent pain and difficulty walking after at least 3 months of conservative treatment, and a listed indication are documented. It considers fixation implants and plantar plate repair experimental, investigational or unproven, and the source does not state an effective date or describe what changed.

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Guillain-Barre Syndrome Treatments (CPB 0732, reviewed 2026-10-21)

Remestemcel-L-rknd (Ryoncil) (CPB 1077, reviewed 2026-05-27)

Guillain-Barre Syndrome Treatments (CPB 0732, reviewed 2025-12-19)

Carbon Dioxide Laser (CPB 0427, reviewed 2026-07-08)

Eagle's and Ernest Syndrome (CPB 0400, reviewed 2026-06-30)

Hammertoe Repair (CPB 0636, reviewed 2026-09-11)

Hammertoe Repair (CPB 0636, reviewed 2025-12-11)

Prior authorization required

Prior authorization required

Prior authorization required

Does AmeriHealth Caritas require prior authorization for J1094?

Does CalViva Health require prior authorization for J1094?

Does Centene require prior authorization for J1094?

Does Community Health Plan of Imperial Valley require prior authorization for J1094?

What insurance policy changes affect HCPCS J1094?

Which payers have updated policy for HCPCS J1094?

How do I get notified when HCPCS J1094 policy changes?

Why do payers change policies for HCPCS J1094?