Q85.9 Insurance Policy Changes

ICD-10 Q85.9 is officially defined as "Phakomatosis, unspecified." code Q85.9 is referenced in 4 tracked payer policy changes from Aetna and Blue Cross & Blue Shield of Mississippi. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code Q85.9 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Aetna · Identified Aug 19, 2026Medium impact
Magnetic Resonance Imaging (MRI) of the Breast (CPB 0105, reviewed 2026-08-06)
Aetna considers breast MRI medically necessary for members who had a recent (within the past year) conventional mammogram and/or breast sonogram, when MRI may affect clinical management. Covered circumstances include detecting local tumor recurrence after mastectomy and breast reconstruction with an implant, assessing residual cancer after an incomplete lumpectomy, and adjunct screening to mammography for women at high genetic risk or with a lifetime breast cancer risk of 20 to 25 percent or more. Breast MRI is considered experimental, investigational or unproven for listed uses such as screening women with average breast cancer risk, evaluating BI-RADS 4 or 5 lesions found on mammogram or ultrasound, and screening women with dense breasts who are asymptomatic and have no additional risk factors. Computer-aided detection is considered integral to breast MRI and is not separately reimbursed.
Aetna · Identified Aug 14, 2026Medium impact
Epilepsy Surgery (CPB 0394, reviewed 2026-06-23)
Aetna covers cerebral hemispherectomy, corpus callosotomy and temporal lobectomy (including selective amygdalohippocampectomy) when the selection criteria are met, and considers them experimental, investigational or unproven when those criteria are not met. Responsive cortical stimulation for adults with intractable focal aware or focal impaired awareness seizures is covered when its listed criteria are met, and Aetna considers responsive cortical stimulation experimental for primary generalized seizures and all other indications. Deep brain stimulation for members with intractable seizures is covered when the medical necessity criteria in CPB 0208 are met. Aetna considers stereotactic radiosurgery for small-volume hypothalamic hamartomas with intractable epilepsy in children medically necessary when the hamartoma is less than 3 cm3 and the area of fusion with the hypothalamus is less than 150 mm2. Magnetic resonance-guided laser interstitial thermal therapy is an alternative to standard surgery where the epilepsy surgery criteria are met, and the Wada test is considered medically necessary. Aetna considers stereotactic radiosurgery for medial temporal lobe epilepsy, chronic pulvinar stimulation, AI-assisted localization for epileptogenic zones, subpial transection surgery, hippocampal electrical stimulation and trigeminal nerve stimulation experimental, investigational or unproven.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders
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.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Genetic Testing for PTEN Hamartoma Tumor Syndrome
Genetic testing for PTEN may be considered medically necessary to confirm a diagnosis when an individual has clinical signs of a PTEN hamartoma tumor syndrome. Targeted testing for a PTEN familial variant may be considered medically necessary in a first-degree relative of a proband with a known PTEN pathogenic variant, and all other genetic testing for PTEN is considered investigational. The 07/31/2026 update changed the policy description and removed ICD-9 diagnosis codes, and the policy statements are unchanged.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code Q85.9?

There are 4 tracked policy changes affecting code Q85.9, including updates from 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 Q85.9?

Payers that have issued tracked updates for code Q85.9 include: Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code Q85.9 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code Q85.9. 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 Q85.9?

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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Magnetic Resonance Imaging (MRI) of the Breast (CPB 0105, reviewed 2026-08-06)

Epilepsy Surgery (CPB 0394, reviewed 2026-06-23)

Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders

Genetic Testing for PTEN Hamartoma Tumor Syndrome

What insurance policy changes affect code Q85.9?

Which payers have updated policy for code Q85.9?

How do I get notified when code Q85.9 policy changes?

Why do payers change policies for code Q85.9?