M31.5 Insurance Policy Changes

ICD-10 M31.5 is officially defined as "Giant cell arteritis with polymyalgia rheumatica." code M31.5 is referenced in 3 tracked payer policy changes from Humana and Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code M31.5 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Humana · Effective Jun 24, 2026Medium impact
Intravenous tocilizumab products (Revised)
Humana Medicare Advantage updated its intravenous tocilizumab prior authorization policy (effective January 1, 2019; revised June 24, 2026). The policy covers four tocilizumab products (Actemra, Tyenne, Tofidence, Avtozma) for five FDA-approved indications: moderately to severely active rheumatoid arthritis (with prior DMARD therapy requirement), systemic juvenile idiopathic arthritis, polyarticular juvenile idiopathic arthritis, cytokine release syndrome, and giant cell arteritis. Key exclusion: combination therapy with other biologics is not covered. Prior authorization is required for all covered indications.
Aetna · Identified Aug 14, 2026Medium impact
Transcranial Doppler Ultrasonography (CPB 0353, reviewed 2026-05-22)
Aetna considers transcranial Doppler ultrasonography medically necessary for indications including assessing collateral blood flow and embolization during carotid endarterectomy, evaluating persons with suspected brain death, detecting microemboli after stroke or transient ischemic attack, evaluating giant cell arteritis, and assessing stroke risk in children aged 2 to 16 years with sickle cell anemia. Aetna considers it experimental, investigational, or unproven for all other indications, including screening for carotid artery stenosis in asymptomatic adults, managing traumatic brain injury, migraine headaches, epilepsy, and evaluating adults with sickle cell anemia. The covered CPT codes are 93886, 93888, 93890, 93892, 93893, 93896, 93897 and 93898 when selection criteria are met.
Aetna · Identified Aug 12, 2026Medium impact
Optical Coherence Tomography of the Head and Neck (CPB 0928, reviewed 2025-12-30)
Optical coherence tomography (OCT) of the head and neck is considered experimental, investigational or unproven for these uses because their effectiveness has not been established: annual OCT follow-up of thyroid ophthalmopathy after orbital decompression, dynamic OCT for actinic keratosis, endoscopic OCT for tympanoplasty, intra-operative wide-field OCT for deep margins in head and neck surgery, OCT for the middle ear, OCT for diagnosis of oral cancerous lesions, OCT for evaluation of voice disorders, OCT for monitoring radiation-induced skin changes in head and neck cancer, OCT angiography for detecting subclinical low perfusion in giant cell arteritis without manifest ocular involvement and in thyroid-associated ophthalmopathy, and OCT otoscopes for imaging the tympanic membrane and middle ear. CPT 0485T through 0486T, 92133 and 92134 are listed as not covered for the indications in this policy, and so are ICD-10 codes for head and neck cancer, thyroid eye disease, tympanic membrane and middle ear disorders, actinic keratosis, radiation-induced skin changes, giant cell arteritis, voice and resonance disorders, and oral cavity cancer screening.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code M31.5?

There are 3 tracked policy changes affecting code M31.5, including updates from Humana, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code M31.5?

Payers that have issued tracked updates for code M31.5 include: Humana, Aetna.

How do I get notified when code M31.5 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code M31.5. 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 M31.5?

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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Intravenous tocilizumab products (Revised)

Transcranial Doppler Ultrasonography (CPB 0353, reviewed 2026-05-22)

Optical Coherence Tomography of the Head and Neck (CPB 0928, reviewed 2025-12-30)

What insurance policy changes affect code M31.5?

Which payers have updated policy for code M31.5?

How do I get notified when code M31.5 policy changes?

Why do payers change policies for code M31.5?