K85.11 Insurance Policy Changes

ICD-10 K85.11 is officially defined as "Biliary acute pancreatitis with uninfected necrosis." code K85.11 is referenced in 5 tracked payer policy changes from Aetna and Health Net. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code K85.11 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Aetna · Effective Dec 3, 2026Medium impact
Plozasiran (Redemplo) (CPB 1096, reviewed 12-2026-03)
Aetna has issued a new clinical policy (CPB 1096, effective 12-2026-03) establishing coverage criteria for plozasiran (Redemplo), a gene-based therapy for familial chylomicronemia syndrome (FCS) in commercial plans. The policy requires precertification, prescriber specialization (cardiology, endocrinology, lipid specialist, geneticist, or FCS specialist), specific diagnostic confirmation, fasting triglyceride thresholds ≥880 mg/dL, concurrent very-low-fat diet adherence, and prohibition of concurrent use with olezarsen (Tryngolza). All other indications are considered experimental.
Health Net · Identified Jun 20, 2026High impact
21-555 Medical Policies - 2nd Quarter 2021
Health Net updated 16 medical policies with new prior authorization requirements, billing code changes, and coverage criteria changes for Q2 2021. Key changes include new CPT codes for ADHD testing that are now not medically necessary, updated HCPCS codes for skin substitutes, and revised criteria for multiple procedures including gender affirming care and spinal cord stimulation.
Health Net · Identified Jun 20, 2026High impact
21-556 Medical Policies - 2nd Quarter 2021
Health Net updated multiple medical policies for Q2 2021, including new policies for TMS treatment, EMG/nerve studies, and nasal valve repair, plus significant updates to ADHD testing codes, gender affirming procedures, and pain management nerve blocks. Multiple CPT, HCPCS, and ICD-10 codes were added, removed, or modified across various specialties.
Health Net · Identified Jun 20, 2026High impact
21-558 Medical Policies - 2nd Quarter 2021
CalViva Health (Medi-Cal) updated multiple medical policies for Q2 2021, affecting prior authorization requirements, billing codes, and coverage criteria across numerous specialties. Key changes include updated CPT codes for ADHD testing, nerve studies, and spinal procedures, plus revised criteria for gender-affirming procedures, pain management, and wound care.
Aetna · Identified Sep 30, 2026Medium impact
Plozasiran (Redemplo) (CPB 1096)
Aetna has issued a new clinical policy (CPB 1096) establishing coverage criteria for plozasiran (Redemplo), a gene-based therapy for familial chylomicronemia syndrome (FCS) in adult commercial members. The policy requires precertification for all claims, restricts prescribing to specialized providers, and mandates specific diagnostic confirmation and triglyceride thresholds before approval. Continuation of therapy requires demonstrated clinical response and concurrent dietary management.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code K85.11?

There are 5 tracked policy changes affecting code K85.11, including updates from Aetna, Health Net. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code K85.11?

Payers that have issued tracked updates for code K85.11 include: Aetna, Health Net.

How do I get notified when code K85.11 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code K85.11. 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 K85.11?

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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Plozasiran (Redemplo) (CPB 1096, reviewed 12-2026-03)

21-555 Medical Policies - 2nd Quarter 2021

21-556 Medical Policies - 2nd Quarter 2021

21-558 Medical Policies - 2nd Quarter 2021

Plozasiran (Redemplo) (CPB 1096)

What insurance policy changes affect code K85.11?

Which payers have updated policy for code K85.11?

How do I get notified when code K85.11 policy changes?

Why do payers change policies for code K85.11?