Z85.038 Insurance Policy Changes

ICD-10 Z85.038 is officially defined as "Personal history of other malignant neoplasm of large intestine." code Z85.038 is referenced in 6 tracked payer policy changes from Blue Cross of Idaho, Blue Cross Blue Shield of North Dakota, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code Z85.038 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Blue Cross of Idaho · Identified Jun 19, 2026High impact
One-to-One for Healthcare - Winter Edition
For 2026, all Blue Cross of Idaho Medicare Advantage plans require members to choose a primary care provider, and specialty care, ancillary care and out-of-network services require a referral from that PCP, with the referral requirements detailed in MAPAP310. Referrals are good for the time span submitted by the PCP, with a maximum of 365 days, and a referral should be created for each specialty type and each condition being treated. Referrals and prior authorizations are separate processes, and the MA authorization process has not changed.
Blue Cross Blue Shield of North Dakota · Identified Jun 19, 2026High impact
Pharmacy Policy Updates
Blue Cross Blue Shield of North Dakota revised many Commercial prior authorization drug policies, with revisions effective April 14, 2026, including oncology drugs such as Adcetris, Keytruda IV, Keytruda SQ, Opdivo IV, Opdivo SQ, Darzalex IV and Trodelvy. The same notice lists Commercial post service claim edit policy revisions effective March 1, 2026 for Aranesp, Epoetin alfa and Mircera, and Commercial medical drug coding updates effective April 1, 2026 with new, removed and changed HCPCS codes.
Blue Cross & Blue Shield of Mississippi · Effective Oct 1, 2026Medium impact
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
Already effective 10/01/2026: ICD-10 diagnosis code QA1.71 was added for Lynch syndrome. Genetic testing of the APC gene may be considered medically necessary for at-risk relatives of individuals with familial adenomatous polyposis or a known APC variant, and for individuals with a differential diagnosis of attenuated FAP, MUTYH-associated polyposis, or Lynch syndrome. Genetic testing of MMR genes (MLH1, MSH2, MSH6, PMS2) may be considered medically necessary for individuals with colorectal or endometrial cancer whose tumor testing suggests germline MMR deficiency or who meet clinical criteria for Lynch syndrome, and for individuals without cancer who meet the Amsterdam or Revised Bethesda criteria or have a 5% or higher predicted risk on a validated risk prediction model when no affected family members have been tested. Testing for germline APC, MUTYH, MMR, EPCAM, SMAD4, BMPR1A, and STK11 variants for inherited colorectal cancer syndromes is considered investigational in all other situations.
Excellus BlueCross BlueShield · Effective Apr 16, 2026Medium impact
Germline Genetic Testing for Hereditary Cancers 2.02.60
Excellus BlueCross BlueShield policy 2.02.60 considers germline genetic testing for hereditary cancer medically appropriate in listed circumstances, including when a blood relative has a known pathogenic or likely pathogenic variant, when a pathogenic or likely pathogenic variant is found on tumor genomic testing, when results aid systemic therapy or surgical decisions, and when individuals meet specific criteria for breast, ovarian, pancreatic, prostate, colorectal, Cowden syndrome, Li-Fraumeni syndrome, hereditary diffuse gastric cancer or familial medullary thyroid carcinoma. Multigene panel testing is considered medically appropriate when an individual meets Policy Statement I, except Policy Statements I.A, I.D and I.G.9. The current effective date is April 16, 2026, and the annual update kept the policy intent unchanged.
Blue Cross Blue Shield of North Dakota · Effective Mar 17, 2026Medium impact
Pharmacy Policies Available Online
Commercial prior authorization medical drug policies have revisions effective March 17, 2026, with many policies adding the Appendix A NQTL Factor Checklist, showing the number of days allowed for authorization durations, and replacing 'coverage' with 'prior authorization validity' in the initial and renewal criteria. Clinical updates include Eylea HD for macular edema following retinal vein occlusion, Breyanzi for relapsed or refractory marginal zone lymphoma, and new appendiceal neoplasm and cancer indications with ICD-10 codes D37.3 and Z85.038. Commercial post service claim edit policies for Trogarzo have revisions effective Feb. 1, 2026.
Aetna · Identified Aug 12, 2026Medium impact
Cetuximab (Erbitux) (CPB 0684, reviewed 2025-12-03)
Aetna's commercial medical policy CPB 0684 covers cetuximab (Erbitux) for listed cancers when the member meets the criteria for that indication. Covered indications are colorectal cancer, head and neck cancer, non-small cell lung cancer, penile cancer and squamous cell skin cancer, each with its own conditions. Precertification is required. Aetna considers all other indications experimental, investigational or unproven.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code Z85.038?

There are 6 tracked policy changes affecting code Z85.038, including updates from Blue Cross of Idaho, Blue Cross Blue Shield of North Dakota, 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 Z85.038?

Payers that have issued tracked updates for code Z85.038 include: Blue Cross of Idaho, Blue Cross Blue Shield of North Dakota, Blue Cross & Blue Shield of Mississippi, Excellus BlueCross BlueShield, Aetna.

How do I get notified when code Z85.038 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code Z85.038. 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 Z85.038?

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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One-to-One for Healthcare - Winter Edition

Pharmacy Policy Updates

Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

Germline Genetic Testing for Hereditary Cancers 2.02.60

Pharmacy Policies Available Online

Cetuximab (Erbitux) (CPB 0684, reviewed 2025-12-03)

What insurance policy changes affect code Z85.038?

Which payers have updated policy for code Z85.038?

How do I get notified when code Z85.038 policy changes?

Why do payers change policies for code Z85.038?