ICD-10 Z01.818 is officially defined as "Encounter for other preprocedural examination." code Z01.818 is referenced in 16 tracked payer policy changes from Blue Cross Blue Shield of Rhode Island, Aetna, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code Z01.818 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
BCBS Rhode Island updated multiple payment policies with key changes including denial of PT/ST/OT claims with ICD-10 codes requiring 7th character 'A' starting Feb 15, 2026, new preventive imaging coverage for screening follow-ups, and updated hearing aid coverage codes effective Jan 1, 2026.
Aetna's updated Clinical Policy Bulletin 0613 (effective 2026-09-03) classifies 3D stereolithographic models and implants as experimental and investigational across cardiac surgery, plastic/reconstructive surgery, penile brachytherapy, cranial implants, and pre-operative planning applications. CPT codes 0559T, 0560T, 0561T, and 0562T are NOT covered for these indications, and claims using these codes for listed procedures will be denied.
This is historical material: Aetna's Clinical Policy Bulletin 0633 on benign skin lesion removal, last reviewed 2025-09-25 and first detected by PolicyChanges on 2026-08-14. Aetna covers removal of common benign lesions (such as moles, skin tags, sebaceous cysts, seborrheic keratoses and dermatofibromas) only when a listed medical reason is documented, such as a biopsy showing dysplasia or malignancy, recurrent irritation, symptoms, inflammation, infection or a lesion that blocks vision, and treats removal without those reasons as cosmetic. No effective date is stated, so confirm this is the current version before relying on it.
Aetna considers anterior segment optical coherence tomography (OCT) experimental, investigational, or unproven for all indications, including detection of glaucoma, evaluation of conjunctival hyperemia and quantification of corneal haziness, because its clinical value has not been established. Anterior segment imaging with the Pentacam, scanning laser ophthalmoscopy (SLO) and scanning laser polarimetry (SLP) is considered experimental, investigational, or unproven because of insufficient evidence of its effectiveness. CPT code 92132 is not covered for the indications listed in the policy, and Aetna members may not be eligible for Pentacam anterior segment imaging for refractive eye surgeries such as LASIK or laser eye surgery.
Aetna's Clinical Policy Bulletin 0633 covers removal of benign skin lesions such as moles, skin tags, sebaceous cysts and seborrheic keratoses when a listed clinical reason applies, such as suspicion of malignancy, recurrent irritation, symptoms, inflammation, or infection. When none of those reasons applies, Aetna treats the removal as cosmetic, and it treats ionized plasma jet therapy and pre-surgical skin ultrasound as experimental. The source is dated by its review on 2026-09-09 and states no effective date for a change, so the billing team should confirm the current bulletin before billing these removals.
Aetna's clinical policy bulletin covers magnetic resonance cholangiopancreatography (MRCP) and lists the indications it considers medically necessary. These include preoperative evaluation of the common bile duct before laparoscopic cholecystectomy in persons with elevated transaminases or common bile duct dilatation on abdominal ultrasound or CT, and members who only need diagnosis of suspected pancreaticobiliary pathology without therapeutic intervention. The bulletin also lists a documented allergy to iodine-based contrast materials or a general history of atopy, altered biliary tract anatomy that precludes ERCP, and unsuccessful ERCP that requires further evaluation. Other listed indications include infants or young children, or adults who are debilitated or uncooperative, in whom ERCP is unsafe or cannot be performed, biliary obstruction in orthotopic liver transplant recipients, a disrupted or disconnected pancreatic duct in acute pancreatitis, diagnosing and monitoring primary sclerosing cholangitis, diagnosing, staging and surveilling pancreatic cancer, and postsurgical surveillance of intraductal papillary mucinous neoplasm of the pancreas. Aetna considers MRCP for all other indications experimental, investigational or unproven. Aetna also considers quantitative MRCP experimental, investigational or unproven for evaluation of bile duct, gallbladder, liver, pancreas and pancreatic duct diseases.
Aetna covers neuropsychological testing when it is needed to assess cognitive impairment due to medical or psychiatric conditions, provided the hours or units requested do not exceed the reasonable time needed to address the clinical questions, the testing techniques are validated for the proposed diagnostic question and for the member's age and population, and the testing does not repeat measurements of the same domain. Neuropsychological testing requested for a mental health diagnosis is considered for coverage through the mental health benefit, and testing requested for a medical diagnosis such as traumatic brain injury, stroke, epilepsy or Alzheimer's disease is considered under the medical benefit. Testing performed for educational, employment, disability qualification or legal or court-related purposes is not covered, and computerized neuropsychological assessment devices such as Cognitrax are considered experimental for screening asymptomatic people and for other indications, including screening and monitoring multiple sclerosis-related cognitive impairment.
Upper gastrointestinal endoscopy (EGD) and GI biopsy are considered medically necessary when the listed criteria are met. Covered high-risk screening includes persons with chronic GERD of 5 years or more who are at risk for Barrett's esophagus, symptomatic pernicious anemia, and cirrhosis with portal hypertension and no prior variceal hemorrhage, and the policy also lists covered diagnostic, therapeutic and sequential or periodic surveillance indications. Routine screening EGD, EGD before bariatric surgery in asymptomatic persons, repeat EGD after a prior normal EGD when symptoms remain unchanged, and EGD for symptoms considered functional in origin are listed as experimental, investigational, or unproven. This is the full policy text is labeled as reviewed 2025-10-29 and includes no change note, and its policy history shows an original effective date of 11/09/2007.
Aetna considers serologic assay screening for antibodies to HSV-1 or HSV-2 in asymptomatic members, including those who are pregnant, experimental, investigational, or unproven because its effectiveness has not been established. The HSV CPT codes 86694, 86695, 86696, 87273, 87274, 87483, 87528 and 87529 are covered only when selection criteria are met, and 87483 and 87529 are not covered for asymptomatic members. CPT 87530 (HSV quantification) is not covered for the indications listed, and for HSV diagnosis in persons with active lesions or symptoms, qualitative PCR testing in CPB 0650 applies.
Aetna considers endometrial ablation medically necessary for women with menorrhagia that is unresponsive to, or has a contraindication to, either dilation and curettage or hormonal therapy, when the severity and persistence of the bleeding would otherwise make the member a candidate for hysterectomy. The selection criteria also require that endometrial sampling or D&C was performed on the same day or within the year before the procedure to exclude cancer, pre-cancer or hyperplasia, that structural abnormalities requiring surgery were excluded, and that a Pap smear and gynecologic examination excluded significant cervical disease. Aetna considers endometrial ablation experimental, investigational, or unproven for all other indications, such as post-menopausal bleeding.
Aetna's Clinical Policy Bulletin 0376 sets the coverage rules for single photon emission computed tomography (SPECT). Non-cardiac SPECT is considered medically necessary for a list of indications, including osteomyelitis, distinguishing bone from soft tissue infection, pulmonary embolism by SPECT ventilation/perfusion scintigraphy, distinguishing Parkinson's disease from essential tremor using DaTSCAN, localization of abscesses, lymphoma and necrosis differentiation, neuroendocrine tumor diagnosis and staging, presurgical ictal detection of seizure focus in epilepsy in place of PET, and thyroid cancer iodine imaging. SPECT for coronary artery disease diagnosis and prognosis is considered medically necessary, except as outlined in the policy's exclusion criteria. SPECT for a list of other uses, including Alzheimer's disease and dementia, attention deficit/hyperactivity disorder, autism, schizophrenia, stroke, and absolute quantitation of myocardial blood flow, is considered experimental, investigational or unproven.
Aetna considers thermography experimental, investigational, or unproven for all indications listed in the policy, including detection and screening for breast cancer, diagnosis of carpal tunnel syndrome, diagnosis of musculoskeletal injuries, and monitoring of diabetes mellitus. Aetna also considers dynamic infrared blood perfusion imaging (DIRI) for intra-operative and post-operative perfusion assessment experimental, investigational, or unproven. CPT 93740 (temperature gradient studies) is not covered for the indications listed.
Aetna's Clinical Policy Bulletin 0796 considers near-infrared (NIR) spectroscopy experimental, investigational or unproven for a long list of indications, including monitoring cerebral perfusion during cardiac and non-cardiac surgery, use in the intensive care and neonatal intensive care settings, evaluating dementia, diagnosing mood disorders and schizophrenia, assessing pain, and treatment of restless legs syndrome. The policy also considers NIR intravascular ultrasound coronary imaging (for example the InfraReDx LipiScan IVUS Imaging System) experimental for all indications. It considers NIR spectroscopy using spatial frequency domain imaging (for example the Ox-Imager CS device) unproven for identifying and evaluating vascular tissue compromise and for all other indications, because there is a lack of clinical studies demonstrating that this approach improves clinical outcomes. Non-contact NIR spectroscopy (for example SnapshotNIR) is considered unproven for intra-operative wound assessment and all other indications because of insufficient evidence of its effectiveness.
Defecography is medically necessary for members with documented chronic constipation when anorectal manometry and rectal balloon expulsion results are negative or inconclusive, and when anterior rectocele, enterocele, inappropriate contraction of the puborectalis muscle, or pelvic organ prolapse is suspected. MR defecography is medically necessary for evaluation or surgical planning of obstructed defecation syndrome and other functional defecation disorders when conventional tests, including conventional defecography, have been inconclusive. Defecography for routine evaluation of constipation and for pre-operative prediction of low anterior resection syndrome is considered experimental, investigational, or unproven, and MR defecography is considered experimental, investigational, or unproven for rectal prolapse, rectal intussusception, other pelvic floor disorders, and other indications.
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.
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.
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