Q87.11 Insurance Policy Changes

ICD-10 Q87.11 is officially defined as "Prader-Willi syndrome." code Q87.11 is referenced in 4 tracked payer policy changes from Wisconsin Medicaid (ForwardHealth), Blue Cross & Blue Shield of Mississippi, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code Q87.11 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Wisconsin Medicaid (ForwardHealth) · Effective Oct 1, 2026Medium impact
ForwardHealth Covers Dental Case Management for Members With Special Health Care Needs
Beginning October 1, 2026, ForwardHealth covers dental case management for members with special health care needs, reimbursed under CDT code D9997 at $100 per visit. Prior authorization is required for more than one visit per member within 180 days, for D9997 billed with moderate to deep dental sedation in that period, for a member whose diagnosis is not a qualifying code but has documented medical necessity, and when the place of service is 15 (Mobile Unit). Prior authorization is not required for the first visit per member, per provider, every six months (180 days).
Blue Cross & Blue Shield of Mississippi · Effective Oct 1, 2025Medium impact
Human Growth Hormone and Insulin-like Growth Factor-1
Already effective 2025-10-01: Prior authorization is required for the growth hormone products listed in this policy, and the policy criteria were extensively revised. Use of samples by an individual will not be considered current or stable therapy to satisfy policy requirements. Egrifta SV and Egrifta WR are considered not medically necessary because the reduction of excess abdominal fat is considered cosmetic, and Genotropin, Humatrope, Ngenla, Omnitrope, Skytrofa, Sogroya and Zomacton are considered not medically necessary because other formulary alternatives are covered by the plan.
Aetna · Identified Aug 18, 2026Medium impact
Hospitalization for the Initiation of Ketogenic Diet (CPB 0226, reviewed 2026-04-23)
Aetna considers hospitalization for initiation of a ketogenic diet medically necessary for intractable seizures, including Doose syndrome and Lennox-Gastaut syndrome, when all listed selection criteria are met, and for persons with glucose transporter protein type 1 deficiency or pyruvate dehydrogenase complex deficiency. Aetna considers hospitalization for initiation of a ketogenic diet of unproven value for all other indications, including adult super-refractory status epilepticus, Alzheimer's disease, autism spectrum disorder, cancer, migraine prevention, multiple sclerosis, Parkinson's disease, schizophrenia and type 2 diabetes. Hospitalization for initiation of the Atkins diet for intractable seizures, mitochondrial diseases, or other indications is considered experimental, investigational, or unproven.
Aetna · Identified Aug 15, 2026Medium impact
Growth Hormone (GH) and Growth Hormone Antagonists (CPB 0170, reviewed 2026-06-26)
Aetna considers somatropin products (Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen and Zomacton), Serostim, Sogroya (somapacitan-beco), Skytrofa (lonapegsomatropin-tcgd) and Somavert (pegvisomant) medically necessary for the listed indications when the criteria for each are met, and considers all other indications experimental, investigational or unproven. The criteria cover pediatric growth hormone deficiency, SGA, Turner syndrome, Prader-Willi syndrome, SHOX deficiency, Noonan syndrome, growth failure from CKD, cerebral palsy, congenital adrenal hyperplasia, cystic fibrosis and Russell-Silver syndrome, adult growth hormone deficiency, HIV-associated wasting or cachexia, and acromegaly. Idiopathic short stature is not considered an illness, so GH is not a covered plan benefit where the plan covers only treatment of disease, illness or injury.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code Q87.11?

There are 4 tracked policy changes affecting code Q87.11, including updates from Wisconsin Medicaid (ForwardHealth), Blue Cross & Blue Shield of Mississippi, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code Q87.11?

Payers that have issued tracked updates for code Q87.11 include: Wisconsin Medicaid (ForwardHealth), Blue Cross & Blue Shield of Mississippi, Aetna.

How do I get notified when code Q87.11 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code Q87.11. 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 Q87.11?

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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ForwardHealth Covers Dental Case Management for Members With Special Health Care Needs

Human Growth Hormone and Insulin-like Growth Factor-1

Hospitalization for the Initiation of Ketogenic Diet (CPB 0226, reviewed 2026-04-23)

Growth Hormone (GH) and Growth Hormone Antagonists (CPB 0170, reviewed 2026-06-26)

What insurance policy changes affect code Q87.11?

Which payers have updated policy for code Q87.11?

How do I get notified when code Q87.11 policy changes?

Why do payers change policies for code Q87.11?