ICD-10 R35.1 is officially defined as "Nocturia." code R35.1 is referenced in 7 tracked payer policy changes from Health Net 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 R35.1 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Health Net updated 22 medical policies in Q4 2019, including new policies for Antithrombin III treatment, implantable hypoglossal nerve stimulation, and video EEG monitoring. Key changes include lowered colorectal cancer screening age to 45, updated bariatric surgery criteria, and multiple billing code additions/removals across various specialties.
Health Net updated 25 medical policies for Q4 2019, affecting prior authorization requirements, billing codes, and coverage criteria across multiple specialties. Key changes include new prior auth requirements for antithrombin III, hypoglossal nerve stimulation, and video EEG, plus updated criteria for bariatric surgery, cardiac risk assessment, and various pain management procedures.
Health Net updated 25+ medical policies in Q4 2019 with significant changes to prior authorization requirements, coverage criteria, and billing codes across multiple specialties. Key changes include updated bariatric surgery criteria, new DNA stool screening age range (45-85), added prior authorization requirements for various procedures, and terminology updates for gender-affirming procedures.
Health Net updated multiple medical policies in Q4 2020, affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties including oxygen therapy, allergy testing, bariatric surgery, wound care, and various diagnostic procedures.
Health Net updated multiple medical policies in Q4 2020, affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties including oxygen therapy, allergy testing, bariatric surgery, and wound care. Most changes involve revised medical necessity criteria and updated CPT/ICD-10 codes that require immediate attention for proper billing and authorization processes.
CalViva Health updated multiple medical policies for Q4 2020 affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties. Key changes include revised oxygen therapy criteria, new ambulatory surgery center redirection requirements, updated bariatric surgery protocols, and modified coverage for various diagnostic and therapeutic services.
Effective 10/01/2026, the code reference adds ICD-10 diagnosis codes QA1.790 (familial cancer syndrome with pathogenic BRCA1 mutation), QA1.791 (familial cancer syndrome with pathogenic BRCA2 mutation), and QA1.792 (Li Fraumeni syndrome), which are listed among the medically necessary codes for prostate specific antigen testing. Prostate specific antigen may be considered medically necessary to differentiate benign from malignant prostate disease in men with listed lower urinary tract symptoms or abnormal studies, to follow prostate cancer after diagnosis, and to screen for malignant prostate disease with documented shared decision making. PSA is considered not medically necessary for all other indications.
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