ICD-10 K50.00 is officially defined as "Crohn's disease of small intestine without complications." code K50.00 is referenced in 31 tracked payer policy changes from Independence Blue Cross, Blue Cross Blue Shield of North Dakota, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code K50.00 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Independence Blue Cross updated policy 08.02.19b for mirikizumab-mrkz (Omvoh) IV effective 10/19/2026. Coverage criteria were revised to align with updated ACG guidelines, removing conventional therapy requirements. Billing teams must now append modifier JA to indicate intravenous administration, and must use the reintroduced ICD-10 diagnosis codes for ulcerative colitis and Crohn's disease claims.
Independence Blue Cross Medicare Advantage revised its policy for IV mirikizumab-mrkz (Omvoh, HCPCS J2267) for ulcerative colitis and Crohn disease, effective October 19, 2026. The policy reinstates a list of UC and CD ICD-10 diagnosis codes and requires modifier JA for intravenous administration, and coverage depends on the medical necessity criteria being documented.
Independence Blue Cross updated its coverage policy for risankizumab-rzaa (Skyrizi) IV effective 2026-10-05, revising criteria for ulcerative colitis and Crohn disease to align with updated American College of Gastroenterology guidelines and removing conventional therapy requirements. Seven inflammatory polyp diagnosis codes (K51.40–K51.419) were removed from covered indications. Pediatric use for both conditions is now classified as experimental/investigational and not covered.
Independence Blue Cross Medicare Advantage updated MA08.153d effective 10/05/2026 to expand risankizumab-rzaa (Skyrizi) IV coverage criteria for ulcerative colitis and Crohn disease by removing conventional therapy requirements and aligning with updated ACG guidelines. Seven inflammatory polyp ICD-10 codes were removed from covered diagnoses, and pediatric use was reclassified as experimental/investigational. Billing teams must verify current member eligibility and remove deleted diagnosis codes from claims processing.
Blue Cross Blue Shield of North Dakota is expanding coverage for Vitamin D Testing by adding 12 new diagnosis codes, including Crohn's disease and kidney stone conditions. This allows billing for Vitamin D tests when patients have these newly covered diagnoses.
Aetna considers measurement of antidrug antibodies and or serum drug levels for adalimumab, certolizumab, golimumab, or infliximab medically necessary for members with Crohn's disease or ulcerative colitis when there is documentation of a loss of response to one of these medications, or for proactive monitoring in members 21 years of age or younger with a confirmed diagnosis of IBD. Aetna considers serum antibody measurements for anti-TNF therapies experimental, investigational, or unproven for all other indications, such as psoriasis, psoriatic arthritis, rheumatoid arthritis, spondyloarthritis, and uveitis. Anti-histone antibody measurement for monitoring infliximab and DNA or mRNA biomarker measurement for predicting therapeutic response in IBD are also considered experimental, investigational, or unproven.
Aetna considers measurement of antidrug antibodies and/or serum drug levels to adalimumab, certolizumab, golimumab or infliximab medically necessary for members with inflammatory bowel disease (Crohn's disease or ulcerative colitis) when there is documentation of a loss of response to one of these medications, or for proactive monitoring in members 21 years of age or younger with a confirmed IBD diagnosis. Measurement of anti-histone antibodies for monitoring infliximab therapy and measurement of DNA or mRNA biomarkers for predicting therapeutic response in IBD are considered experimental, investigational or unproven. Serum level and antibody testing of anti-TNF blocking agents for all other indications, such as psoriasis, psoriatic arthritis, rheumatoid arthritis, spondyloarthritis and uveitis, is also considered experimental, investigational or unproven.
Independence Blue Cross reissued Policy 08.00.64i (Natalizumab/Tysabri and biosimilars) with updated ICD-10 diagnosis codes effective 10/01/2025. The policy replaced the broad 'G35 Multiple sclerosis' code with three specific codes (G35.A, G35.C1, G35.D) and added HCPCS code Q5134 for the biosimilar natalizumab-sztn (Tyruko). Medical necessity criteria remain substantially unchanged but now explicitly cover highly active relapsing MS, active secondary progressive MS, and Crohn's disease per updated FDA labeling.
Aetna's Clinical Policy Bulletin 0783 (reviewed 2026-10-27) confirms that in vivo analysis technologies for gastrointestinal and urothelial lesions, including confocal laser endomicroscopy, narrow-band imaging, chromoendoscopy and optical biopsy systems, are considered experimental, investigational or unproven for the listed indications. Claims for these services with the listed CPT codes (such as 43206, 43252 and +0397T) and ICD-10 diagnoses will be denied under this policy, so billing staff should review how these services are coded and documented before submission.
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.
Autologous skeletal myoblast transplantation, intra-coronary and intra-myocardial autologous bone marrow cell transplantation, and intra-arterial or intra-muscular autologous mononuclear bone marrow cell transplantation are considered experimental, investigational, or unproven because effectiveness has not been established. Autologous or allogeneic bone marrow-derived mesenchymal stem cell transplantation is likewise considered experimental, investigational, or unproven for conditions including acute myocardial infarction, diabetes, multiple sclerosis, knee osteoarthritis, spinal cord injury, rheumatoid arthritis, Crohn's disease, and peripheral nerve repair. CPT codes 0263T, 0264T, 0265T, 38240, and 38241 and HCPCS code C9782 are listed as not covered for the listed indications, and the ICD-10 codes for those indications are listed as not covered for these services.
Aetna considers autologous hematopoietic cell transplantation medically necessary for adults 18 to 69 years old with rapidly progressive scleroderma (systemic sclerosis) at risk of organ failure. This applies when active interstitial lung disease is present with a forced vital capacity or diffusing capacity of the lung for carbon monoxide below 70% of predicted, or when previous scleroderma-related renal disease is present, and the member meets the transplanting institution's selection criteria or, if there are none, has none of the listed exclusion criteria. Aetna considers autologous or allogeneic hematopoietic cell transplantation experimental, investigational, or unproven for conditions including multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, Crohn's disease, ulcerative colitis, myasthenia gravis, type I diabetes mellitus, age-related macular degeneration, amyotrophic lateral sclerosis, polycythemia vera, and thrombotic thrombocytopenic purpura.
In inflammatory bowel disease (IBD) and rheumatoid arthritis, TPMT gene or phenotypic testing is medically necessary before starting 6-mercaptopurine or azathioprine, with only one TPMT assay per member per lifetime, and NUDT15 gene analysis is medically necessary before starting any thiopurine (azathioprine, mercaptopurine or thioguanine). For IBD, fecal calprotectin is medically necessary for managing Crohn's disease and ulcerative colitis and for distinguishing IBD from irritable bowel syndrome, fecal lactoferrin is medically necessary for distinguishing IBD from irritable bowel syndrome, and 6-thioguanine nucleotide and 6-methylmercaptopurine nucleotide measurements are medically necessary to monitor compliance in patients not responding to 6-mercaptopurine and azathioprine therapy and to assess suspected toxicity. Many other biomarkers, antibody panels and genetic tests, including NOD2/CARD15 genotyping, PredictSURE IBD, Monitr Crohn's Disease Test and procalcitonin measurement, are considered experimental, investigational or unproven.
Aetna considers nutritional support a medical item only when it is given by feeding tube or intravenously to a member with permanent non-function or disease of the structures that normally permit food to reach the small bowel, or with small bowel disease that impairs digestion and absorption of an oral diet, and when adequate nutrition cannot be met by dietary adjustment or oral supplements. Aetna does not cover nutritional support taken orally unless state law mandates it, and it does not cover banked breast milk, food supplements, specialized infant formulas, or vitamins and minerals taken orally. Parenteral nutrition is considered medically necessary when adequate intake is not possible by oral or tube feeding, such as after documented enteral failure, when the gastrointestinal tract must be totally non-functioning for a period of time, or when structural or functional bowel disease makes oral and tube feedings inappropriate.
Aetna considers allogeneic hematopoietic cell transplantation medically necessary for a list of primary immunodeficiency disorders, including adenosine deaminase deficiency, chronic granulomatous disease, common variable immune deficiency (CVID), DiGeorge syndrome, hemophagocytic lymphohistiocytosis, severe combined immunodeficiency (SCID), Wiskott-Aldrich syndrome, and others listed in the policy. Aetna considers hematopoietic cell transplantation experimental, investigational, or unproven for activated phosphoinositide 3-kinase delta syndrome, complement deficiency, granulomatous-lymphocytic interstitial lung disease, inflammatory bowel disease, juvenile idiopathic arthritis, and pulmonary alveolar proteinosis, and for autologous transplantation for primary immunodeficiency disorders. TREC testing is considered medically necessary following allogeneic hematopoietic stem cell transplant for SCID.
Aetna's Clinical Policy Bulletin 0606 covers hematopoietic cell transplantation for autoimmune diseases and other listed conditions. Aetna considers autologous transplant medically necessary for adults aged 18 to 69 with rapidly progressive scleroderma (systemic sclerosis) at risk of organ failure when either active interstitial lung disease with an FVC or DLCO below 70% of predicted is present, or previous scleroderma-related renal disease is present, and the member meets the transplanting institution's selection criteria or, where none exist, has none of the listed exclusion criteria. Aetna considers autologous or allogeneic transplant experimental, investigational or unproven for many autoimmune diseases, including multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, Crohn's disease, ulcerative colitis, type 1 diabetes and myasthenia gravis, and for miscellaneous conditions such as age-related macular degeneration, amyotrophic lateral sclerosis, polycythemia vera and thrombotic thrombocytopenic purpura.
Aetna considers the ADAMTS13 assay medically necessary for assessing prognosis in persons with thrombotic thrombocytopenic purpura (TTP), and for distinguishing hematopoietic stem cell transplant-associated thrombotic microangiopathy (HSCT-TMA, also called transplant-associated TMA) from TTP in persons with overlapping features when the test will be used to inform treatment. Aetna considers the assay experimental, investigational, or unproven for the uses it lists because of insufficient evidence, including sepsis-associated thrombotic microangiopathy, hemolytic uremic syndrome, acute myelogenous leukemia, colorectal cancer survival, COVID-19, cerebral infarction, and ADAMTS13 mutation testing for non-cirrhotic portal hypertension.
Aetna's clinical policy bulletin 0655 sets the coverage rules for adalimumab (Humira) and its biosimilars under commercial medical plans. Adalimumab is considered medically necessary for rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, Crohn's disease, ulcerative colitis, plaque psoriasis, hidradenitis suppurativa, non-infectious uveitis, Behcet's disease, pyoderma gangrenosum and immune checkpoint inhibitor-related inflammatory arthritis when the listed criteria are met. The policy also states that Hulio has been discontinued as of 1/1/2026, and that adalimumab-fkjp is the unbranded generic of Hulio.
Aetna considers colonic motility studies (colonic manometry) medically necessary to guide decision-making for surgery in children with refractory colonic motility or defecatory disorders. Aetna considers radionuclide gastric emptying studies medically necessary for the evaluation of gastrointestinal motility disorders and gastroparesis. Aetna considers magnetic resonance enterography medically necessary to evaluate and monitor Crohn's disease and other small bowel disorders. The following are considered experimental, investigational, or unproven because their effectiveness or clinical utility has not been established: 3D high-resolution manometry for quantification of esophago-gastric junction contractility; body surface gastric mapping (Gastric Alimetry) for gastric motility and gastroduodenal disorders and all other indications; electrogastrography; the gastric emptying breath test for gastroparesis and all other indications; high resolution esophageal pressure topography (HREPT); the immunoglobulin G antibody blood test to identify food triggers associated with irritable bowel syndrome (Biomerica inFoods IBS); the Malabsorption Evaluation Panel (Mayo Clinic Laboratories) for evaluation of intestinal dysbiosis, irritable bowel syndrome, malabsorption or small intestinal overgrowth of bacteria, and all other indications; the PillSense System for detection of upper gastrointestinal bleeding; and the SmartPill wireless capsule for measuring gastric emptying parameters for gastric disorders, intestinal motility disorders, and all other indications, because of inadequate published evidence of its diagnostic performance and clinical utility over conventional means of measuring gastric emptying. The policy lists CPT 91117 as covered for its listed indications and CPT 91132 and 91133 (electrogastrography) as not covered for those indications.
Aetna's Clinical Policy Bulletin 0849 covers teduglutide (Gattex) for commercial medical plans and requires precertification from Aetna for participating providers and members in applicable plan designs. The drug must be prescribed by or in consultation with a gastroenterologist or a prescriber who specializes in short bowel syndrome. Aetna considers it medically necessary for short bowel syndrome in adults who have been dependent on parenteral nutrition and/or IV fluids for at least 12 months and receive them at least 3 times a week, or in members under 18 years of age who receive parenteral nutrition and/or IV fluids to account for at least 30% of caloric and/or fluid/electrolyte needs. Continuation is considered medically necessary when parenteral support requirements have decreased by at least 20% from baseline on therapy, or when the member has been weaned off parenteral support. Aetna considers all other indications experimental, investigational or unproven, including Crohn's disease, ulcerative colitis, graft-versus-host disease and type-2 diabetes mellitus.
Aetna's commercial policy covers natalizumab (Tysabri) and natalizumab-sztn (Tyruko) for adult Crohn's disease and for relapsing forms of multiple sclerosis and clinically isolated syndrome, and precertification is required for members in applicable plan designs. Initial approval for Crohn's disease requires that the adult member has received another biologic indicated for moderately to severely active Crohn's disease and has been tested for anti-John Cunningham virus (JCV) antibodies. Initial approval for multiple sclerosis or clinically isolated syndrome requires anti-JCV antibody testing. The drug must be prescribed by or in consultation with a gastroenterologist for Crohn's disease or a neurologist for multiple sclerosis. Continuation for Crohn's disease requires remission or a positive clinical response, and continuation for multiple sclerosis or clinically isolated syndrome requires disease stability or improvement. Aetna considers concurrent use with other disease-modifying MS agents, immunosuppressants, or tumor necrosis factor inhibitors experimental, investigational, or unproven, and also considers natalizumab experimental for acute ischemic stroke, drug-resistant epilepsy, chronic inflammatory demyelinating polyneuropathy, neuromyelitis optica, Rasmussen encephalitis, stem cell mobilization, and ulcerative colitis.
Aetna considers Omvoh (mirikizumab-mrkz) medically necessary for commercial members with moderately to severely active ulcerative colitis or Crohn's disease only when the member has a contraindication, intolerance or ineffective response to the listed lower-cost targeted immune modulators. For both conditions, the listed alternatives are Entyvio, Skyrizi, either Pyzchiva or Stelara, Tremfya, and either Avsola, Inflectra or Renflexis, with a one-month trial of each. Precertification is required, and Aetna considers continuation of therapy medically necessary for members who achieve or maintain remission or a positive clinical response.
Aetna's Clinical Policy Bulletin for risankizumab-rzaa (Skyrizi) covers the drug for commercial medical plans when the member meets the listed criteria for plaque psoriasis, psoriatic arthritis, Crohn's disease, or ulcerative colitis. Precertification is required for intravenous Skyrizi, and the drug must be prescribed by or in consultation with a dermatologist (plaque psoriasis), a rheumatologist or dermatologist (psoriatic arthritis), or a gastroenterologist (Crohn's disease and ulcerative colitis). Aetna considers all other indications experimental, investigational, or unproven, and considers concomitant use with another biologic or targeted synthetic drug for the same indication experimental.
Feraheme, Ferrlecit, Injectafer, Monoferric and Venofer are medically necessary only for commercial members who have a contraindication, intolerance or ineffective response to the lower cost alternatives generic ferumoxytol, generic iron sucrose, generic sodium ferric gluconate and INFeD (iron dextran) for the labeled indication. Precertification is required for Feraheme, Ferrlecit, generic sodium ferric gluconate, Injectafer, Monoferric, Venofer and generic iron sucrose in applicable plan designs. Intravenous iron is considered experimental, investigational or unproven for other indications, including acute mountain sickness and anemia of inflammation, and it is contraindicated for genetic hemochromatosis or hemochromatosis secondary to iron overload.
Aetna considers guselkumab (Tremfya) medically necessary for commercial members with moderate to severe plaque psoriasis, active psoriatic arthritis, moderately to severely active ulcerative colitis, and moderately to severely active Crohn's disease when the listed criteria are met, and considers all other indications experimental, investigational, or unproven. Plaque psoriasis approval requires members to be 6 years of age or older and weigh at least 40 kg, along with body surface area or prior-treatment criteria. Precertification is required for intravenous guselkumab (Tremfya IV) for all Aetna participating providers and members in applicable plan designs.
Aetna's commercial clinical policy bulletin 0844 covers fecal bacteriotherapy. It considers fecal microbiota transplant medically necessary for Clostridium difficile infection (CDI) confirmed by a positive C. difficile toxin stool test that has recurred after at least one course of adequate antibiotic therapy. It considers a single rectal dose of Rebyota (fecal microbiota, live-jslm) medically necessary for preventing CDI when the policy's criteria are met, and it considers other listed indications, including alcoholic hepatitis, Crohn's disease, ulcerative colitis and irritable bowel syndrome, experimental, investigational, or unproven.
As last reviewed on May 21, 2026, Aetna considers multidisciplinary intestinal rehabilitation programs medically necessary for persons with parenteral nutrition-dependent intestinal failure. These programs usually include a team of dietitians, nurses, gastroenterologists, neonatologists and pediatric surgeons, and focus on diet and nutrition, medications, surgery and rehabilitation. Aetna considers intestinal rehabilitation programs experimental, investigational or unproven for all other indications.
Aetna considers double balloon enteroscopy medically necessary for dilation of small bowel strictures in Crohn's disease, evaluating suspected small bowel malignancies, evaluating the colon after incomplete colonoscopy, suspected Meckel's diverticulum with an indefinite imaging work-up, obscure GI bleeding with objective evidence of recurrent bleeding, removing entrapped foreign bodies in the small bowel, removing large polyps greater than 10 mm in Peutz-Jeghers syndrome, GI bleeding when the small intestine is the source, and use with ERCP in individuals with surgically altered upper GI anatomy. Aetna considers double balloon enteroscopy experimental, investigational or unproven for other indications, including detection of small bowel neuroendocrine tumors, small bowel varices, treatment of intussusception, treatment of angioectasia (type 1 small bowel vascular lesions), and treatment of post-operative bile leakage after hepaticojejunostomy. Combined double balloon enteroscopy and endoscopic ultrasound for evaluation of Crohn's disease is also considered experimental, investigational or unproven.
Aetna considers certolizumab pegol (Cimzia) medically necessary for commercial medical plans only for members who have a contraindication, intolerance or ineffective response to the listed lower cost targeted immune modulators, with waived trial requirements for members who are pregnant or breastfeeding. Precertification is required of all Aetna participating providers and members in applicable plan designs, and the medication must be prescribed by or in consultation with a specialist such as a rheumatologist, gastroenterologist, dermatologist or oncologist depending on the indication. Aetna considers Cimzia experimental, investigational or unproven for concomitant use with other biologics or targeted synthetic drugs for the same indication and for Behcet's disease, microscopic colitis, ocular inflammation/uveitis, sarcoidosis and severe asthma.
Wireless capsule endoscopy of the small bowel is medically necessary for suspected small bowel bleeding after prior inconclusive upper and lower GI endoscopic studies performed during the current episode of illness, for initial diagnosis of suspected Crohn disease without evidence of disease on small bowel follow-through and upper and lower endoscopy, for an established Crohn disease diagnosis when there are unexpected changes in disease course or response to treatment, and for small bowel surveillance in hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome. Other uses are investigational, including evaluating the extent of known Crohn disease or ulcerative colitis, the esophagus, the colon including colonic polyps or colon cancer, other GI diseases not presenting with GI bleeding, initial evaluation of acute upper GI bleeding, lower GI bleeding with major risks for colonoscopy, and patients following an incomplete colonoscopy. The patency capsule is investigational, and magnetic capsule endoscopy is investigational for unexplained upper abdominal complaints and all other indications.
Independence Blue Cross reissued policy 08.00.64i for natalizumab (Tysabri) and biosimilar natalizumab-sztn (Tyruko) with updated ICD-10 diagnosis codes. Three MS-related codes were added (G35.A, G35.C1, G35.D) and one generic code (G35) was removed. Medical necessity criteria remain substantively unchanged. The policy covers MS relapsing forms and Crohn's disease with existing approval requirements.
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