Does AmeriHealth Caritas require prior authorization for J1436?

AmeriHealth Caritas lists J1436 on AmeriHealth Caritas Louisiana prior authorization service list for medicaid managed plans. Verify with the payer before scheduling.

Does CountyCare Health Plan require prior authorization for J1436?

CountyCare Health Plan lists J1436 on CountyCare Prior Authorization Look-Up Tool (All Codes) for medicaid managed plans (list dated April 23, 2026). Verify with the payer before scheduling.

Does Fidelis Care require prior authorization for J1436?

Fidelis Care lists J1436 on Fidelis Care 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 J1436?

There are 4 tracked policy changes affecting HCPCS J1436, including updates from Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for HCPCS J1436?

Payers that have issued tracked updates for HCPCS J1436 include: Aetna.

How do I get notified when HCPCS J1436 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to HCPCS J1436. 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 J1436?

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

J1436 Insurance Policy Changes

HCPCS J1436 is officially defined as "Injection, etidronate disodium, per 300 mg." HCPCS J1436 is referenced in 4 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 J1436 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Aetna · Identified Oct 25, 2026Medium impact
Core Decompression for Avascular Necrosis (CPB 0753, reviewed 2026-10-21)
Aetna's Clinical Policy Bulletin 0753 on core decompression for avascular necrosis lists a last review date of 10/21/2026, but the text does not describe what changed. Aetna considers core decompression medically necessary for early or pre-collapse (stage I or II) avascular necrosis of the hip, and considers it experimental, investigational or unproven for late or post-collapse (stage III or higher) hip avascular necrosis and for avascular necrosis of other joints. Aetna also considers several adjunctive treatments experimental, investigational or unproven for avascular necrosis of any joint, including bone marrow concentrate, platelet-rich plasma, bisphosphonates, bone morphogenic proteins and synthetic bone graft substitutes.
Aetna · Identified Aug 19, 2026Medium impact
Zoledronic Acid (CPB 0524, reviewed 2026-02-12)
Aetna's clinical policy bulletin covers zoledronic acid for commercial medical plans. Zoledronic acid 5 mg (Reclast or generic) is considered medically necessary for postmenopausal osteoporosis, osteoporosis in men, glucocorticoid-induced osteoporosis, Paget's disease of bone, and treatment-related bone loss in men with prostate cancer receiving androgen deprivation therapy, when the listed criteria are met. Zoledronic acid 4 mg (formerly branded Zometa) is considered medically necessary for bone metastases from a solid tumor, certain breast cancer indications, hypercalcemia of malignancy, Langerhans cell histiocytosis with bone disease, multiple myeloma, and systemic mastocytosis with osteopenia or osteoporosis. Aetna considers all other indications experimental, investigational, or unproven.
Aetna · Identified Aug 19, 2026Medium impact
Kidney Transplantation (CPB 0493, reviewed 2026-07-30)
Aetna considers kidney transplantation medically necessary for members who meet the transplanting institution's selection criteria. Where no institution criteria apply, the member must complete an evaluation and be accepted by the kidney transplant committee, meet the transplanting institution's protocol age criteria, have no malignancy except the listed exceptions, and meet the policy's infection, cardiovascular, pulmonary, hepatic and severity-of-disease criteria. Aetna considers belatacept (Nulojix) medically necessary for preventing acute rejection in kidney transplant recipients who are sero-positive for Epstein-Barr virus, and equine anti-thymocyte globulin (Atgam) medically necessary for prophylaxis or treatment of allograft rejection in renal transplantation in combination with conventional therapy, and for moderate to severe aplastic anemia in persons who are not suitable candidates for bone marrow transplantation, while gene microarray, donor-derived cell-free DNA, urinary biomarker, TruGraf and AI/ML graft survival tests are experimental, investigational, or unproven for the indications listed.
Aetna · Identified Aug 15, 2026Medium impact
Core Decompression for Avascular Necrosis (CPB 0753, reviewed 2025-10-30)
Aetna considers core decompression medically necessary for early or pre-collapse avascular necrosis of the hip, meaning stage I or II before X-ray changes are evident, and the presence of cysts is considered stage II under the Ficat classification. Core decompression is experimental, investigational or unproven for late or post-collapse hip disease (stage III or higher, when X-ray changes have occurred), for avascular necrosis of other joints such as the ankle, elbow, knee, mandibular condyle and shoulder, and for post-arthroscopic osteonecrosis. Adjunctive treatments for avascular necrosis of any joint, including bone morphogenic proteins, growth factors, mesenchymal stem cells, platelet-rich plasma, synthetic bone graft substitutes and biological augmentation with retro-drilling core decompression, are also listed as experimental, investigational or unproven.

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Core Decompression for Avascular Necrosis (CPB 0753, reviewed 2026-10-21)

Zoledronic Acid (CPB 0524, reviewed 2026-02-12)

Kidney Transplantation (CPB 0493, reviewed 2026-07-30)

Core Decompression for Avascular Necrosis (CPB 0753, reviewed 2025-10-30)

Prior authorization required