HCPCS J1826 is officially defined as "Injection, interferon beta-1a, 30 mcg." HCPCS J1826 is referenced in 6 tracked payer policy changes from Sentara Health Plans, Premera Blue Cross, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS J1826 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
Premera's December 2024 medical policy and coding update adds medical necessity criteria for lymphedema and lipedema surgery, a new shoulder arthroplasty policy, and new or revised criteria for drugs including Ocrevus Zunovo, Dupixent, Ebglyss, Leqselvi and Wegovy. It also lists coding updates that require review for medical necessity and prior authorization, including cervical spine surgery codes 63001, 63015, 63040, 63050, 63051, 63075, 63081 and 63265, and it places infusion drugs such as Tyruko and Alyglo under site-of-service review.
Aetna considers physical therapy, perineoplasty, and vestibulectomy (local or total) medically necessary for vulvodynia and vulvar vestibulitis. Vestibulectomy is considered medically necessary for persons who have failed conservative measures (including vulvar care, physical therapy, and pharmacotherapy including analgesics) and who have had a musculoskeletal evaluation that ruled out factors such as pelvic muscle over-activity and myofascial or other biomechanical disorders, or a 3-month trial and failure of treatments for those disorders. Acupuncture, botulinum toxin, laser therapy, sacral neuromodulation, spinal cord stimulation, TENS, hypnotherapy, and many other listed treatments are considered experimental, investigational, or unproven for this indication because their effectiveness has not been established.
For commercial medical plans, Aetna considers the following medically necessary for Dupuytren's contracture: collagenase clostridium histolyticum (Xiaflex, see CPB 1061), intralesional glucocorticoid injection in early-stage disease, ortho-voltage radiation for early-stage stage N and N/I disease, and percutaneous needle aponeurotomy when criteria are met. Percutaneous needle aponeurotomy is medically necessary for adults with a finger flexion contracture that has a palpable cord in a metacarpophalangeal or proximal interphalangeal joint, a contracture of at least 20 degrees, and a positive table top test, meaning the affected finger or fingers and the palm cannot be placed flat on a table at the same time. Aetna considers treatments such as anti-tumor necrosis factor therapy, autologous fat grafting, extracorporeal shock wave therapy, night-time splinting after fasciectomy or dermofasciectomy, the Digit Widget, and ultrasound therapy experimental, investigational, or unproven.
Aetna considers the treatments listed in this bulletin experimental, investigational or unproven for Alzheimer's disease because their effectiveness for that indication has not been established. The list includes acupuncture, applied behavior analysis, deep brain stimulation, gene therapy, intravenous immunoglobulins, lithium, music therapy, statins, stem cell therapy, transcranial magnetic and direct current stimulation, vagus nerve stimulation, and monoclonal antibodies such as solanezumab, bapineuzumab, crenezumab and semorinemab. The CPT, HCPCS and ICD-10 codes named in the bulletin are not covered for the indications the bulletin lists, including Alzheimer's disease (ICD-10 G30.0 through G30.9).
Prior authorization is required for the multiple sclerosis drugs in this policy. Step 1 generic preferred agents are dimethyl fumarate, fingolimod, glatiramer and teriflunomide. Step 2 brand agents require trial and failure of one Step 1 agent, except Lemtrada, which requires trial and failure of two Step 1 or Step 2 agents with one of them a Step 1 agent, and Ocrevus products, which do not require it for primary progressive MS. Bafiertam, Briumvi, Copaxone, Mavenclad, Mayzent, Ponvory, Tascenso ODT, Tecfidera and Vumerity are not covered on any BCBSMS formulary. A 10/05/2026 update combined the medical covered agents into one Preferred Agents table, added Rebif Rebidose as a Step 2 brand preferred agent, and removed the renewal clinical improvement requirement for all agents except Ampyra.
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