Q21.0 Insurance Policy Changes

ICD-10 Q21.0 is officially defined as "Ventricular septal defect." code Q21.0 is referenced in 6 tracked payer policy changes from Excellus BlueCross BlueShield, Aetna, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code Q21.0 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Excellus BlueCross BlueShield · Effective Apr 16, 2026Medium impact
Lung and Lobar Lung Transplant 7.02.10
Lung transplantation is considered medically appropriate for carefully selected candidates with irreversible, progressively disabling, end-stage pulmonary disease who have adequate cardiac status, absence of infection (or absence of extrapulmonary infection in cystic fibrosis), no malignancy within five years other than non-melanomatous skin cancer, and documented compliance with medical management. Candidates with HIV are a contraindication unless CD4 count is greater than 200 cells/mm3, HIV-1 RNA is undetectable, they have been on stable antiretroviral therapy for more than three months, and all other criteria are met. The current effective date is April 16, 2026.
Aetna · Identified Oct 26, 2026Medium impact
Rebreathing of Inert Gas for Measurement of Cardiac Output and Validation of Intra-Cardiac Shunt (CPB 0714, reviewed 2026-10-20)
Aetna clinical policy bulletin 0714, last reviewed October 20, 2026, covers rebreathing of inert gas for measuring cardiac output and for validating intra-cardiac shunt. The policy considers three uses experimental, investigational or unproven because their effectiveness has not been established: measuring cardiac output, predicting survival in persons with pulmonary hypertension, and validating intra-cardiac shunt.
Aetna · Identified Aug 15, 2026Medium impact
Rebreathing of Inert Gas for Measurement of Cardiac Output and Validation of Intra-Cardiac Shunt (CPB 0714, reviewed 2025-11-25)
Rebreathing of inert gas for the measurement of cardiac output, for the prediction of survival in persons with pulmonary hypertension, and for the validation of intra-cardiac shunt is considered experimental, investigational, or unproven because the effectiveness of these approaches has not been established. The policy lists ICD-10 codes I27.0, I27.20 to I27.29 (pulmonary hypertension) and Q21.0 to Q21.9 (congenital malformations of cardiac septa, intra cardiac shunt) as not covered for the indications listed in the policy. The policy lists no specific CPT or HCPCS codes for measuring cardiac output with inert gas rebreathing.
Aetna · Identified Aug 14, 2026Medium impact
Catheter-Directed Cardiac Procedures (CPB 0292, reviewed 2026-08-04)
Aetna considers transcatheter closure of atrial septal defects with FDA-approved devices medically necessary for closure of a fenestration after the Fontan procedure, for a secundum ASD with a Qp:Qs ratio of at least 1.5, right ventricular enlargement and pulmonary vascular resistance under 5 Wood units (or 5 to 8 Wood units that fall below 5 with PAH treatment), and for an ASD with strong suspicion of paradoxical embolism. Transcatheter PFO occlusion is medically necessary for adults aged 18 to 60 after a non-lacunar cryptogenic stroke with an atrial septal aneurysm or a large right-to-left shunt of at least 20 bubbles, and transcatheter VSD closure is medically necessary for complex VSDs in patients at high risk for standard surgical closure. Transcatheter PDA closure is medically necessary with the Amplatzer duct occluder or another FDA-approved device for that indication, while closure for migraine, heart failure interatrial shunts, the APTURE system, the Neovasc Reducer, the Nit-Occlud Le VSD coil and AngioVac debulking are considered experimental, investigational or unproven.
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
Heart/Lung Transplant
Heart/lung transplantation is considered medically necessary for carefully selected individuals with end-stage cardiac and pulmonary disease, including irreversible primary pulmonary hypertension with heart failure, cystic fibrosis with severe heart failure, emphysema with severe heart failure, and pulmonary fibrosis with uncontrollable pulmonary hypertension or heart failure. Heart/lung retransplantation after a failed primary heart/lung transplant may be considered medically necessary for individuals who meet the criteria for heart/lung transplantation. Heart/lung transplantation in all other situations is considered investigational.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code Q21.0?

There are 6 tracked policy changes affecting code Q21.0, including updates from Excellus BlueCross BlueShield, Aetna, Blue Cross & Blue Shield of Mississippi. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code Q21.0?

Payers that have issued tracked updates for code Q21.0 include: Excellus BlueCross BlueShield, Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code Q21.0 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code Q21.0. 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 Q21.0?

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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Lung and Lobar Lung Transplant 7.02.10

Rebreathing of Inert Gas for Measurement of Cardiac Output and Validation of Intra-Cardiac Shunt (CPB 0714, reviewed 2026-10-20)

Rebreathing of Inert Gas for Measurement of Cardiac Output and Validation of Intra-Cardiac Shunt (CPB 0714, reviewed 2025-11-25)

Catheter-Directed Cardiac Procedures (CPB 0292, reviewed 2026-08-04)

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

Heart/Lung Transplant

What insurance policy changes affect code Q21.0?

Which payers have updated policy for code Q21.0?

How do I get notified when code Q21.0 policy changes?

Why do payers change policies for code Q21.0?