J45.998 Insurance Policy Changes

ICD-10 J45.998 is officially defined as "Other asthma." code J45.998 is referenced in 13 tracked payer policy changes from UnitedHealthcare, Excellus BlueCross BlueShield, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code J45.998 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

UnitedHealthcare · Effective Oct 1, 2026Medium impact
Xolair ® (Omalizumab)
UnitedHealthcare Community Plan of Indiana has revised its Xolair (omalizumab) policy effective October 1, 2026, clarifying that provider-administered subcutaneous injections are covered for chronic urticaria, IgE-mediated food allergy, moderate-to-severe persistent asthma, and nasal polyps, while self-administered injections fall under pharmacy benefits. The policy also explicitly identifies conditions where Xolair is NOT covered (seasonal/perennial allergic rhinitis, atopic dermatitis, acute bronchospasm, anaphylaxis). Indiana is now included in coverage (previous policy excluded it).
Excellus BlueCross BlueShield · Effective Jul 16, 2026Medium impact
Allergy Testing 2.01.10
Percutaneous, combined percutaneous and intracutaneous, intracutaneous, patch, photo patch, photo, inhalation bronchial challenge, ingestion challenge, and gammaglobulin IgE tests are medically appropriate in the diagnosis of the allergic patient, with allergen-specific IgE medically appropriate only under specified circumstances. Allergen-specific IgG when the criteria are not met, the leukocyte histamine release test, ophthalmic and direct nasal mucous membrane tests, peanut allergen-specific ELISA testing, and cytotoxicity, provocative, and Rebuck skin window tests are investigational, and allergy testing for treatment programs such as tolerance induction programs is investigational. The July 16, 2026 update was an annual review with the policy intent unchanged.
Aetna · Identified Oct 17, 2026Medium impact
Esophageal and Airway pH Monitoring (CPB 0667, reviewed 2026-10-07)
Aetna Clinical Policy Bulletin 0667 on esophageal and airway pH monitoring, reviewed 2026-10-07, considers esophageal pH monitoring medically necessary for listed indications, such as refractory reflux in members with chest pain after cardiac evaluation, and for evaluating vomiting in infants up to 3 months of age. The policy considers multi-channel intraluminal impedance testing medically necessary for certain reflux and dysphagia indications, and considers airway pH monitoring, pharyngeal pH monitoring and airway impedance measurement experimental, investigational or unproven. This is an older source dated 2026-10-07, which is historical material, and it states no effective date.
Aetna · Identified Oct 10, 2026Medium impact
Repository Corticotropin Injection (Acthar Gel and Purified Cortrophin Gel) (CPB 0762, reviewed 2026-10-08)
Aetna considers repository corticotropin injection (Acthar Gel only) medically necessary for infantile spasms in members less than 2 years of age, and considers all other indications experimental, investigational, unproven, or not medically necessary. Precertification of Acthar Gel or Purified Cortrophin Gel is required of all Aetna participating providers and members in applicable plan designs. Purified Cortrophin Gel is considered experimental, investigational, or unproven for infantile spasms because it is not FDA-approved, nor has a compendial use, for this indication, and use of Acthar Gel in combination with Purified Cortrophin Gel is considered experimental, investigational, or unproven.
Aetna · Identified Oct 5, 2026Medium impact
Infrared Therapy (CPB 0604, reviewed 2026-09-09)
Aetna considers infrared coagulation medically necessary for anal dysplasia and for members with grade I, II, or III internal hemorrhoids that are painful or persistently bleeding. Low-level infrared light therapy is considered experimental, investigational, or unproven for a long list of indications, including osteoarthritis, migraines, stroke, and diabetes mellitus, and the infrared glove is unproven for Raynaud's syndrome and all other indications. CPT 46930 is covered when selection criteria are met, while CPT 97026 and HCPCS codes A4639 and E0221 are not covered for the listed indications.
Aetna · Identified Sep 29, 2026Medium impact
Adoptive Immunotherapy and Cellular Therapy (CPB 0641, reviewed 2026-09-25)
Aetna considers adoptive immunotherapy using tumor-infiltrating lymphocytes (TILs) or interleukin-2 activated lymphokine-activated killer (LAK) cells experimental, investigational or unproven for a long list of indications, including Alzheimer disease, esophageal, gynecologic, head and neck, hepatocellular, lung, glioblastoma, renal cell, pancreatic and other malignancies, because there is not adequate evidence that it is more beneficial than IL-2 alone. Melanoma is excluded from that list for lifileucel (Amtagvi), an FDA-approved TIL therapy. Cellular therapy (including embryonic cell, fresh cell, glandular, live cell, MAGE-A4 cell, organotherapy and xenotransplant therapy) is considered experimental, investigational or unproven for a long list of indications due to lack of adequate evidence, including angina, arthritis, diabetes, heart failure, hypertension, ischemic heart disease, ischemic stroke, motor neuron diseases, osteoarthritis and focal cartilage defects of the knee, peripheral arterial disease, and traumatic brain injury. Cancer is excluded from that list for afamitresgene autoleucel (Tecelra), an FDA-approved MAGE-A4-directed TCR T-cell therapy for synovial sarcoma. The policy also lists CAR T-cell therapy for solid tumors and virus-specific T-cell lymphocyte therapy for viral infections as experimental, investigational or unproven. HCPCS code S2107 (adoptive immunotherapy per course of treatment) and M0075 (cellular therapy) are listed as not covered for the indications in the policy.
Aetna · Identified Aug 17, 2026Medium impact
Hair Analysis (CPB 0300, reviewed 2026-04-17)
Aetna considers chemical hair analysis experimental, investigational or unproven, except for diagnosis of suspected chronic arsenic poisoning, and considers hair analysis of brain-derived neurotrophic factor as a predictor of developing psychopathological symptoms in childhood experimental, investigational or unproven. Microscopic evaluation of hair structure (trichogram) may be medically necessary as part of the work-up of members with alopecia or abnormal-appearing or abnormally growing hair.
Aetna · Identified Aug 15, 2026Medium impact
Extracorporeal Immunoadsorption (Prosorba Column) (CPB 0355, reviewed 2026-05-26)
Aetna considers extracorporeal immunoadsorption (ECI, Prosorba column) medically necessary for hemolytic uremic syndrome and idiopathic thrombocytopenic purpura with clinical evidence of serious bleeding with platelet count below 50,000 or the potential for serious bleeding with platelet count below 20,000, for last resort treatment of life-threatening systemic lupus erythematosus when conventional therapy has failed, for moderate-to-severe rheumatoid arthritis in members who have failed other treatments, for myasthenic crisis when conventional therapy has failed, and for pemphigus vulgaris resistant to standard therapy. ECI is experimental, investigational, or unproven for all other indications, including allergic asthma, atopic dermatitis, anti-phospholipid syndrome, COVID-19, dermatomyositis, heart failure, hepatitis B, idiopathic inflammatory myopathy, interstitial lung disease or pneumonia, and prevention of attacks or progression of neuromyelitis optica spectrum disorder. CPT 36516 is covered if the selection criteria are met.
Aetna · Identified Aug 14, 2026Medium impact
Exhaled Breath Tests (CPB 0691, reviewed 2025-10-16)
Hydrogen breath testing is covered when selection criteria are met: for evaluating suspected lactose intolerance after a 2-week trial of a lactose-free diet when symptoms persist, and for diagnosing small intestinal bacterial overgrowth (SIBO) in symptomatic patients with suspected motility disorders. Measurement of exhaled nitric oxide is covered when criteria are met for evaluating asthma and monitoring response to long-term control therapy in members aged 5 years and older. Hydrogen breath testing for all other indications, including irritable bowel syndrome, prediction of bowel preparation adequacy before colonoscopy, and small bowel transit time or gastroparesis, is considered experimental, investigational, or unproven. Exhaled nitric oxide for all other indications, including acute mountain sickness, pulmonary hypertension, chronic cough, and chronic obstructive pulmonary disease, is considered experimental, investigational, or unproven. Exhaled breath condensate pH for asthma, inflammatory bowel disease, lung cancer, obstructive sleep apnea, pulmonary diseases and SARS-CoV-2 is considered experimental, investigational, or unproven. Gastric emptying breath testing for gastroparesis and for all other indications, exhaled breath temperature, exhaled volatile organic compounds, and breath analysis for tuberculosis are also considered experimental, investigational, or unproven because their effectiveness has not been established.
Aetna · Identified Aug 13, 2026Medium impact
Palivizumab (Synagis) (CPB 0318, reviewed 2025-11-24)
Aetna considers palivizumab (Synagis) medically necessary for commercial medical plans for up to 5 doses per RSV season to prevent serious lower respiratory tract disease caused by RSV, when a member has a qualifying diagnosis such as prematurity, chronic lung disease of prematurity, hemodynamically significant congenital heart disease, cystic fibrosis or profound immunocompromise and the associated criteria are met. Palivizumab is excluded for members who have received nirsevimab-alip (Beyfortus) in the same RSV season. The American Academy of Pediatrics stated that in July 2025 it no longer routinely recommends using Synagis.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Respiratory Devices
This Blue Cross Blue Shield Association policy states that spacers for use with metered dose inhalers and peak flow meters for patients with respiratory disorders are medically necessary. Special features such as computerized recording devices, including on the AirWatch system, are considered convenience enhancements and are not eligible for additional coverage. When noninvasive ear or pulse oximetry testing is performed in a professional's office, the pulse oximeter is considered integral to the professional's medical or surgical care, and separate payment will not be made for it. The 03/27/2026 policy update removed the ICD-9 diagnosis codes.
Health Net · Identified Jun 20, 2026Medium impact
20-552 Earn Incentives through the Prop 56 VBP Program
Health Net's Prop 56 Value-Based Payment (VBP) program pays add-on payments to Medi-Cal providers in Fresno, Kings and Madera counties for meeting specific measures in prenatal and postpartum care, early childhood care, chronic disease management and behavioral health integration. Payments apply to services performed on or after July 1, 2019, when submitted as a clean claim or encounter within one year from the date of service with a qualifying CPT and/or ICD-10 code. Payment amounts are higher for at-risk members, for example $70 for a prenatal care visit and $105 for an at-risk prenatal care visit, and $80 for diabetes care and $120 for at-risk diabetes care.
Health Net · Identified Jun 20, 2026Medium impact
20-554 Earn Incentives through the Prop 56 VBP Program
Health Net's Prop 56 Value-Based Payment (VBP) program pays add-on payments to Medi-Cal providers in Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus and Tulare counties for meeting specific measures in prenatal and postpartum care, early childhood care, chronic disease management and behavioral health integration. Payments apply to services performed on or after July 1, 2019, when submitted as a clean claim or encounter within one year from the date of service with a qualifying CPT and/or ICD-10 code. Payment amounts are higher for at-risk members, for example $70 for a prenatal care visit and $105 for an at-risk prenatal care visit, and $80 for diabetes care and $120 for at-risk diabetes care.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code J45.998?

There are 13 tracked policy changes affecting code J45.998, including updates from UnitedHealthcare, Excellus BlueCross BlueShield, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code J45.998?

Payers that have issued tracked updates for code J45.998 include: UnitedHealthcare, Excellus BlueCross BlueShield, Aetna, Blue Cross & Blue Shield of Mississippi, Health Net.

How do I get notified when code J45.998 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code J45.998. 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 J45.998?

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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Xolair ® (Omalizumab)

Allergy Testing 2.01.10

Esophageal and Airway pH Monitoring (CPB 0667, reviewed 2026-10-07)

Repository Corticotropin Injection (Acthar Gel and Purified Cortrophin Gel) (CPB 0762, reviewed 2026-10-08)

Infrared Therapy (CPB 0604, reviewed 2026-09-09)

Adoptive Immunotherapy and Cellular Therapy (CPB 0641, reviewed 2026-09-25)

Hair Analysis (CPB 0300, reviewed 2026-04-17)

Extracorporeal Immunoadsorption (Prosorba Column) (CPB 0355, reviewed 2026-05-26)

Exhaled Breath Tests (CPB 0691, reviewed 2025-10-16)

Palivizumab (Synagis) (CPB 0318, reviewed 2025-11-24)

Respiratory Devices

20-552 Earn Incentives through the Prop 56 VBP Program

20-554 Earn Incentives through the Prop 56 VBP Program

What insurance policy changes affect code J45.998?

Which payers have updated policy for code J45.998?

How do I get notified when code J45.998 policy changes?

Why do payers change policies for code J45.998?