ICD-10 U07.1 is officially defined as "COVID-19." code U07.1 is referenced in 31 tracked payer policy changes from Health Net, Blue Cross Blue Shield of Wyoming, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code U07.1 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Health Net updated 24 medical policies in Q2 2020, including new prior authorization requirements for burn surgery and skin substitutes, coverage changes for various procedures, and updated billing codes for multiple specialties. Key changes include new COVID-19 testing guidelines, updated ADHD assessment criteria, and revised coverage for mechanical stretching devices.
This policy update includes multiple changes to prior authorization requirements, coverage criteria, and billing codes across various medical services. Key changes include new policies for burn surgery and pediatric oral therapy, updates to ADHD assessment criteria, new COVID-19 testing guidelines, and various code additions/deletions that may affect payment.
CalViva Health updated medical policies for Q2 2020 affecting Medi-Cal members in Fresno, Kings, and Madera counties. Multiple policies were added or revised with new coverage criteria, code updates, and prior authorization requirements for various procedures including burn surgery, cardiac rehabilitation, genetic testing, and COVID-19 diagnostics.
BCBSWY updated COVID-19 billing requirements to include specific specimen handling codes (G2023, G2024, C9803, 99000, 99001) for non-in-house testing to ensure proper cost share waivers. The policy also waives inpatient prior authorization for COVID-19 treatment (U07.1 diagnosis) and extends telemedicine benefits through August 31, 2020.
Aetna reviewed its clinical policy on exhaled breath tests (CPB 0691) on 2026-10-27, and the text does not state a new effective date or a specific new requirement. It sets out which breath tests Aetna treats as medically necessary: hydrogen breath testing for lactose intolerance or small intestinal bacterial overgrowth, and exhaled nitric oxide for asthma in members aged 5 and older. Other breath tests, including breath condensate pH, gastric emptying breath tests and exhaled volatile organic compound tests, are listed as not covered or experimental for the indications named.
Aetna considers ECMO medically necessary for neonates who meet all of these criteria: a listed diagnosis (congenital diaphragmatic hernia, hyaline membrane disease, meconium aspiration, persistent fetal circulation, possible cardiac anomaly, refractory neonatal septic shock, respiratory distress syndrome, or uncontrollable air leak), gestational age of at least 34 weeks, birth weight of 2,000 grams or greater, and age less than 10 days (preferably less than 7 days). For children and adults, ECMO and extracorporeal life support are considered medically necessary for listed diagnoses when the risk of death is very high despite optimal conventional therapy, including ARDS, a short-term bridge to heart, liver, lung or heart-lung transplantation or to durable mechanical circulatory support, support following heart surgery to ease the transition from cardiopulmonary bypass to ventilation, non-necrotizing pneumonias, primary graft failure after transplant, pulmonary contusion, refractory pediatric septic shock, smoke inhalation injury, and other reversible causes of respiratory or cardiac failure unresponsive to all other measures. Aetna considers ECMO experimental, investigational, or unproven for all other indications, including acute coronary syndromes, acute massive pulmonary embolism, burns not accompanied by ARDS, cardiogenic shock or smoke inhalation injury, sepsis other than refractory pediatric septic shock, refractory status asthmaticus, tuberculosis, and drug overdose.
Aetna considers adoptive immunotherapy using tumor-infiltrating lymphocytes (TILs) or interleukin-2 activated lymphokine-activated killer (LAK) cells experimental, investigational or unproven for a long list of indications, including Alzheimer disease, esophageal, gynecologic, head and neck, hepatocellular, lung, glioblastoma, renal cell, pancreatic and other malignancies, because there is not adequate evidence that it is more beneficial than IL-2 alone. Melanoma is excluded from that list for lifileucel (Amtagvi), an FDA-approved TIL therapy. Cellular therapy (including embryonic cell, fresh cell, glandular, live cell, MAGE-A4 cell, organotherapy and xenotransplant therapy) is considered experimental, investigational or unproven for a long list of indications due to lack of adequate evidence, including angina, arthritis, diabetes, heart failure, hypertension, ischemic heart disease, ischemic stroke, motor neuron diseases, osteoarthritis and focal cartilage defects of the knee, peripheral arterial disease, and traumatic brain injury. Cancer is excluded from that list for afamitresgene autoleucel (Tecelra), an FDA-approved MAGE-A4-directed TCR T-cell therapy for synovial sarcoma. The policy also lists CAR T-cell therapy for solid tumors and virus-specific T-cell lymphocyte therapy for viral infections as experimental, investigational or unproven. HCPCS code S2107 (adoptive immunotherapy per course of treatment) and M0075 (cellular therapy) are listed as not covered for the indications in the policy.
Aetna considers temsirolimus (Torisel or generic temsirolimus) medically necessary as a single agent for subsequent treatment of locally advanced, recurrent, or metastatic endometrial carcinoma, for relapsed or refractory mantle cell lymphoma, and for advanced renal cell carcinoma. It also considers it medically necessary for specified soft tissue sarcoma subtypes, for rhabdomyosarcoma (maximum 12 cycles, with cyclophosphamide and vinorelbine), and for subsequent treatment of advanced, recurrent/metastatic, or inoperable PEComa in uterine sarcoma. Aetna considers all other indications experimental, investigational, or unproven, and considers continuation of therapy medically necessary when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.
Aetna considers the ADAMTS13 assay medically necessary for assessing prognosis in persons with thrombotic thrombocytopenic purpura (TTP), and for distinguishing hematopoietic stem cell transplant-associated thrombotic microangiopathy (HSCT-TMA, also called transplant-associated TMA) from TTP in persons with overlapping features when the test will be used to inform treatment. Aetna considers the assay experimental, investigational, or unproven for the uses it lists because of insufficient evidence, including sepsis-associated thrombotic microangiopathy, hemolytic uremic syndrome, acute myelogenous leukemia, colorectal cancer survival, COVID-19, cerebral infarction, and ADAMTS13 mutation testing for non-cirrhotic portal hypertension.
Aetna considers ribavirin for inhalation medically necessary for the treatment of hospitalized infants and young children with severe lower respiratory tract infections due to respiratory syncytial virus (RSV). Aetna considers all other indications experimental, investigational, or unproven, including the cationic liposome encapsulated ribavirin spray for the treatment of acute pneumonia. Ribavirin for inhalation is not indicated for use in adults.
Aetna's Clinical Policy Bulletin 0814 considers remote ischemic conditioning experimental, investigational, or unproven for many indications because its effectiveness has not been established. The listed indications include acute coronary syndromes in individuals undergoing percutaneous coronary intervention, prevention of contrast-induced acute kidney injury, improvement of outcomes in individuals with acute ischemic stroke undergoing intravenous thrombolysis, improvement of outcomes following orthopedic surgery, sepsis management, and treatment of ulcerative colitis. The bulletin states that there are no specific codes for remote ischemic conditioning.
For commercial medical plans, Aetna considers remdesivir (Veklury) medically necessary for COVID-19 in non-hospitalized, high-risk members when all listed criteria are met. Hospitalized members receiving Veklury for COVID-19 are managed under the inpatient benefit, and the criteria apply only to coverage in the outpatient setting. Aetna considers the combined use of remdesivir and human monoclonal antibodies for COVID-19, and remdesivir for the prevention of COVID-19 in children and adolescents, experimental, investigational, or unproven.
Aetna considers ravulizumab-cwvz (Ultomiris) medically necessary for paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome (aHUS), generalized myasthenia gravis (gMG) and neuromyelitis optica spectrum disorder (NMOSD) when the listed criteria are met. Aetna considers concurrent use of ravulizumab-cwvz and eculizumab experimental, investigational, or unproven. Aetna considers ravulizumab-cwvz experimental, investigational, or unproven for other indications, including amyotrophic lateral sclerosis (ALS), aplastic anemia and COVID-19, and notes that this list is not all-inclusive. Precertification is required of all Aetna participating providers and members in applicable plan designs. The policy was last reviewed 08/11/2026 and lists a next review date of 05/27/2027.
Aetna considers quantitative EEG (brain mapping, also called BEAM) medically necessary only as an adjunct to traditional EEG for specified uses, including ambulatory EEG recording to facilitate later expert visual interpretation, continuous EEG monitoring by frequency-trending in the operating room or ICU, and topographic voltage and dipole analysis in pre-surgical evaluations for intractable epilepsy. Aetna considers quantitative EEG experimental, investigational or unproven for all other indications, including attention disorders, autism spectrum disorders, depression, schizophrenia, bipolar disorder, insomnia, fibromyalgia, post-traumatic stress disorder and post-concussion syndrome. The BrainScope One System (Ahead 300) is considered experimental, investigational or unproven for evaluation of concussion or traumatic brain injury.
Aetna considers extracorporeal immunoadsorption (ECI, Prosorba column) medically necessary for hemolytic uremic syndrome and idiopathic thrombocytopenic purpura with clinical evidence of serious bleeding with platelet count below 50,000 or the potential for serious bleeding with platelet count below 20,000, for last resort treatment of life-threatening systemic lupus erythematosus when conventional therapy has failed, for moderate-to-severe rheumatoid arthritis in members who have failed other treatments, for myasthenic crisis when conventional therapy has failed, and for pemphigus vulgaris resistant to standard therapy. ECI is experimental, investigational, or unproven for all other indications, including allergic asthma, atopic dermatitis, anti-phospholipid syndrome, COVID-19, dermatomyositis, heart failure, hepatitis B, idiopathic inflammatory myopathy, interstitial lung disease or pneumonia, and prevention of attacks or progression of neuromyelitis optica spectrum disorder. CPT 36516 is covered if the selection criteria are met.
Aetna considers cardiopulmonary exercise testing (CPET, CPT 94621) medically necessary for listed conditions after standard testing, including echocardiography, pulmonary function testing with diffusion capacity, and oxygen desaturation measured on the 6-minute walk test. The listed conditions include post-operative evaluation of chronic thromboembolic pulmonary hypertension after pulmonary thromboendarterectomy, developing exercise prescriptions for cardiac or pulmonary rehabilitation, evaluating exercise capacity and response to therapy in chronic heart failure patients considered for heart transplantation or other advanced therapies, and evaluating post-acute sequelae of COVID-19 (Long COVID). CPET is considered experimental, investigational or unproven as a screening exercise test, as a routine pre-operative assessment, and as a first-line diagnostic test for possible cardiac or pulmonary pathology.
Aetna covers home pulse oximetry as durable medical equipment for members with chronic lung disease, severe cardiopulmonary disease, or neuromuscular disease involving the muscles of respiration, when the device is used to determine home oxygen liter flow for ambulation, exercise, or sleep, to monitor a person on a home ventilator, for short-term (one month) monitoring when a physician-directed change in home oxygen liter flow is needed, when weaning from home oxygen, or for interstage monitoring of children undergoing the Norwood procedure for hypoplastic left heart syndrome. Capnography (end-tidal carbon dioxide monitoring) is covered for members with congenital central alveolar hypoventilation syndrome. Home pulse oximetry is considered experimental, investigational, or unproven for asthma management, for evaluating and teaching CPAP, for maintenance or continuous monitoring other than for persons on a ventilator, for predicting the need for adenotonsillectomy in children, and when used alone as a screening or testing technique for suspected obstructive sleep apnea.
Aetna considers entry into a medically supervised outpatient pulmonary rehabilitation program medically necessary when the member has a chronic pulmonary disease or another condition that affects pulmonary function, dyspnea at rest or with exertion, reduced exercise tolerance that restricts activities of daily living or work, symptoms that persist despite appropriate medical management, and a moderate to severe functional pulmonary disability. That disability is shown either by a maximal exercise stress test with VO2max of 20 ml/kg/min or less (about 5 METS) or by FEV1, FVC, FEV1/FVC, or DLCO below 60 % of predicted, and the member must be physically able, motivated, and willing to participate. A typical course extends for up to 6 weeks or 36 hours of therapy. Repeat programs are considered not medically necessary, except in connection with lung transplantation or lung volume reduction surgery, and routine, maintenance, or non-skilled care is considered not medically necessary. Pulmonary rehabilitation is considered experimental, investigational, or unproven for all other indications.
Aetna considers medroxyprogesterone acetate injection (Depo-Provera CI or generic 150 mg/mL) medically necessary for pregnancy prevention and for gender dysphoria when the listed criteria are met. It considers the etonogestrel subdermal implant (Nexplanon) medically necessary for pregnancy prevention and for primary or secondary dysmenorrhea associated with endometriosis in adolescents, and it considers progestin-releasing IUDs (Kyleena, Mirena, Skyla and Liletta) medically necessary for contraception or heavy menstrual bleeding. Progesterone intramuscular injection is medically necessary for amenorrhea or abnormal uterine bleeding due to hormonal imbalance without organic pathology, and the policy considers it experimental, investigational, or unproven for other indications, including pregnancy prevention, twin pregnancies, endometrial hyperplasia, premenstrual syndrome and stroke.
Aetna's policy covers plerixafor (Mozobil or generic plerixafor) for hematopoietic stem cell mobilization when it is given after a granulocyte-colony stimulating factor such as filgrastim, after chemo-mobilization, or as part of a gene therapy protocol, and when it is not used beyond 4 consecutive days or after stem cell harvest or apheresis is complete. Continuation of therapy is considered medically necessary for members who meet the initial selection criteria. Aetna considers plerixafor experimental, investigational or unproven for all other indications, including the conditions listed in the policy such as acute leukemias, sickle cell disease, WHIM syndrome and neutropenia treatment.
Aetna covers enfuvirtide (Fuzeon) for commercial medical plans in treatment of HIV-1 infection when the member has viremia despite 3 or more prior months of therapy with at least one appropriate regimen, or has viremia and documented resistance or intolerance to at least one appropriate regimen. Continuation is covered when the member has had a positive or stable virologic response to enfuvirtide. Aetna considers enfuvirtide experimental, investigational, or unproven for treatment-naive HIV-infected persons and for treatment of COVID-19.
Aetna considers Adakveo (crizanlizumab-tmca) medically necessary for reducing the frequency of vaso-occlusive crises in members 16 years of age or older with sickle cell disease, when the member has had at least one vaso-occlusive crisis in the previous 12 months and either has HbSC, HbSβ+, or another genotypic variant of sickle cell disease, or has HbSS or HbSβ0 genotype and has had an inadequate response to, an intolerance of, or a contraindication to hydroxyurea, or will use Adakveo with concurrent hydroxyurea. Continuation is considered medically necessary when the frequency of vaso-occlusive crises has been reduced since starting therapy or has stayed reduced, and Adakveo must be prescribed by or in consultation with a hematologist or sickle cell disease specialist. All other indications are considered experimental, investigational, or unproven, including treatment and prevention of adverse outcomes in COVID-19. This policy covers commercial medical plans, and Medicare criteria are in Medicare Part B Criteria.
Aetna Clinical Policy Bulletin 0670 covers omalizumab (Xolair) and omalizumab-igec (Omlyclo) for commercial medical plans, and precertification is required for these products in applicable plan designs. Aetna considers omalizumab medically necessary for asthma, chronic rhinosinusitis with nasal polyps (CRSwNP), chronic spontaneous urticaria, IgE-mediated food allergy, immune checkpoint inhibitor-related toxicity and systemic mastocytosis when the listed criteria are met. Aetna considers all other indications experimental, investigational or unproven, and the Site of Care Utilization Management Policy applies to these products.
Aetna's Clinical Policy Bulletin 0641 considers adoptive immunotherapy using tumor-infiltrating lymphocytes or IL-2-activated LAK cells, and a broad list of cellular therapies, experimental, investigational or unproven for the indications it names. Those indications include most cancers, Alzheimer disease, COVID-19, heart failure, ischemic heart disease, orthopedic and musculoskeletal disorders, and minimization of general immunosuppression in kidney transplant recipients. The policy names exceptions for lifileucel (Amtagvi) in melanoma and afamitresgene autoleucel (Tecelra) in synovial sarcoma, and it lists CAR T-cell therapy for solid tumors and virus-specific T-cell lymphocyte therapy for viral infections among the unproven uses.
Actemra (tocilizumab) and Olumiant (baricitinib) are considered medically necessary for treating COVID-19 in hospitalized adults who meet the listed oxygen, ventilation or ECMO criteria, and their cost is included within the hospital DRG. Veklury (remdesivir) is considered medically necessary for hospitalized adult and pediatric patients up to a maximum of 10 days, and for non-hospitalized patients with mild-to-moderate COVID-19 who are at high risk for progression, up to a maximum of 3 days. All other drugs, including those authorized under an Emergency Use Authorization, are considered investigational.
Blue Cross & Blue Shield of Mississippi covers FDA-approved COVID-19 RT-PCR testing using an upper respiratory specimen when it is medically appropriate for individuals with signs and symptoms compatible with COVID-19 without an alternative explanatory diagnosis. The same testing is medically appropriate for asymptomatic individuals with known or suspected recent exposure when their provider determines it is appropriate, and before elective surgeries and procedures involving the mouth, nose, oropharynx, nasopharynx, respiratory tract, gastrointestinal tract, or requiring general anesthesia or monitored anesthesia care (MAC). COVID-19 RT-PCR testing not approved by the FDA, including any test authorized under an EUA, is considered investigational, and FDA-approved testing performed for screening of asymptomatic individuals is considered not medically necessary. The policy was reviewed on 07/01/2026 with statements unchanged, and the code reference was updated to remove CPT codes 0240U and 0241U.
Effective for dates of service beginning May 1, 2020, HCPCS V2785 was placed in ASC payment group 11, priced at $3,418.65, and that payment includes acquisition of corneal tissue and the facility payment for the associated surgical procedure. Effective March 1, 2020, COVID-19 medication co-pays are waived when ICD-10 code U07.1 is entered on the claim transmittal, and prior authorization is required for all immune globulin products listed on the Preferred Drug List effective April 1, 2020.
The February 2022 Health First Colorado provider bulletin (B2200475) covers several changes. Effective February 1, 2022, claims requiring electronic visit verification (EVV) go through pre-payment review, and claims without the needed EVV records may deny with EOB 3054. The bulletin also describes at-home OTC COVID-19 test billing under HCPCS E1399 with modifier U1 from January 15, 2022, requires the ordering provider's NPI on DMEPOS claims effective July 1, 2022, and notes that 24 physician-administered drug codes became subject to prior authorization effective January 18, 2022.
BCBS Wyoming has updated COVID-19 diagnostic testing coding guidance with new ICD-10 codes and clarified coverage rules. The policy specifies that asymptomatic and pre-surgical COVID-19 testing is covered when medically appropriate, but not for return-to-work or surveillance purposes.
Blue Cross Blue Shield of Wyoming updated COVID-19 diagnosis and testing billing guidance with new codes. The policy clarifies that new COVID-related diagnosis codes J12.82, M35.81, and M35.89 will not waive cost sharing, while U07.1 should still be included for COVID treatment claims.
This is a comprehensive COVID-19 FAQ document that covers multiple billing and administrative guidance areas. The title mentions COVID-19 vaccine administration rate increases as of August 9, but the actual policy content is a general FAQ updated April 2024 covering billing codes, prior authorization exemptions, and various COVID-19 related procedures.
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