Z85.46 Insurance Policy Changes

ICD-10 Z85.46 is officially defined as "Personal history of malignant neoplasm of prostate." code Z85.46 is referenced in 18 tracked payer policy changes from Excellus BlueCross BlueShield, Blue Cross & Blue Shield of Mississippi, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code Z85.46 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Excellus BlueCross BlueShield · Effective Oct 15, 2026High impact
Magnetic Resonance Imaging (MRI) of the Prostate - (Effective Date - 2026-10-15) 6.01.46
MRI of the pelvis is considered medically appropriate for men with suspected prostate cancer who meet one of the listed indications, including men aged 40 to 75 with a PSA greater than 3 ng/ml or a very suspicious digital rectal exam plus a listed high-risk feature, men aged 45 to 75 with a PSA greater than 3 ng/ml or a very suspicious digital rectal exam, and men older than 75 with a PSA of 4 ng/ml or greater or a very suspicious digital rectal exam. A 06/18/26 update removed very low risk from the NCCN initial risk stratification criteria, added new criteria for suspected prostate cancer and for restaging, removed criteria for non-metastatic prostate cancer previously treated with prostatectomy, radiation therapy, ablation hormonal therapy or chemotherapy where PSA does not fall after prostatectomy, and removed the salvage local therapy criteria. Serial MRIs are considered not medically necessary when monitoring an elevated PSA for suspected prostate cancer, and MR guidance for needle placement is not medically necessary for prostate biopsy.
Blue Cross & Blue Shield of Mississippi · Effective Oct 1, 2026Medium impact
Prostate Specific Antigen (PSA)
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.
Blue Cross & Blue Shield of Mississippi · Effective Oct 1, 2026Medium impact
Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)
Genetic testing for BRCA1, BRCA2 and PALB2 variants may be considered medically necessary in individuals with cancer who meet listed criteria, such as a personal history of breast cancer diagnosed at age 45 years or younger, a personal history of epithelial ovarian carcinoma at any age, or a personal history of exocrine pancreatic cancer at any age. Testing of BRCA1 and BRCA2 in individuals with a family history of cancer who do not meet the criteria, testing of PALB2 in individuals who do not meet the criteria, and genetic testing in minors are considered investigational. The code reference section was updated on 10/01/2026 to add ICD-10 diagnosis codes QA1.790 and QA1.791 and to remove deleted CPT code 96040.
Excellus BlueCross BlueShield · Effective Sep 17, 2026Medium impact
Radiopharmaceuticals for the Treatment of Cancer 6.01.44
This medical policy sets when radiopharmaceutical cancer treatments are considered medically appropriate: Xofigo for castration-resistant prostate cancer with symptomatic bone metastases, Pluvicto for PSMA-positive metastatic castration-resistant prostate cancer, Lutathera for somatostatin receptor-positive neuroendocrine tumors, strontium-89 chloride for bone pain from confirmed skeletal metastases, and HICON for thyroid carcinoma. Treatment regimens beyond the U.S. Food and Drug Administration approved regimen are considered investigational. The current version is effective September 17, 2026, with an annual review, and the policy intent is unchanged.
Excellus BlueCross BlueShield · Effective Sep 17, 2026Medium impact
Radiopharmaceuticals for the Treatment of Cancer 6.01.44
Policy 6.01.44 considers radiopharmaceutical treatments for cancer medically appropriate only within their FDA-approved regimen, and requests in excess of that regimen are considered investigational. Xofigo is considered medically appropriate for castration-resistant prostate cancer with symptomatic bone metastases and no known visceral metastatic disease or bulky regional lymph nodes greater than 3 cm on imaging within the past 30 days. Pluvicto, Lutathera, strontium-89 chloride, and HICON (sodium iodide I 131) are each considered medically appropriate only when their listed criteria are met. The September 18, 2025 review added a new Pluvicto indication and removed Azedra and Zevalin because both are no longer commercially available.
Excellus BlueCross BlueShield · Effective Sep 17, 2026Medium impact
Laboratory Testing for the Screening and Management of Prostate Cancer 2.02.48
Excellus BlueCross BlueShield policy 2.02.48 considers biomarker tests for prostate cancer that diagnose or determine a risk score investigational, including PROGENSA PCA3, 4Kscore, Prostate Health Index and ConfirmMDx. Gene expression analysis to guide management of prostate cancer is considered medically appropriate only under the listed criteria, and ArteraAI is considered investigational for management of prostate cancer. The current version is effective September 17, 2026, and its most recent change is an annual review with the policy intent unchanged.
Blue Cross Blue Shield of North Dakota · Effective Sep 9, 2026Medium impact
Pharmacy Policies Available Online
Blue Cross Blue Shield of North Dakota updated its commercial pharmacy policies, and the revisions to the commercial prior authorization medical drug policies are effective September 9, 2026. Revisions to the commercial post service claim edit medical drug policies are effective August 1, 2026. Many of the prior authorization policies now state the number of days allowed for initial and renewal authorization durations, replace specific contraindications in the Universal Criteria with general language that the member does not have any FDA contraindications, and add covered ICD-10 diagnosis codes in Appendix 1.
Excellus BlueCross BlueShield · Effective Aug 20, 2026Medium impact
Focal Therapies for Prostate Cancer Treatment 7.01.01
Cryosurgery and high-intensity focused ultrasound (HIFU) for recurrent prostate cancer are medically appropriate when prostate cancer has recurred after radiation therapy, as shown by a positive repeat biopsy, and there is no metastatic disease. Cryotherapy or other focal therapies, including HIFU, used for routine primary therapy for localized prostate cancer are considered investigational, as are vascular-targeted photodynamic therapy, irreversible electroporation, NanoKnife tissue ablation, laser interstitial thermal therapy, transurethral ultrasound ablation, NanoTherm magnetic field induction, and high energy water vapor thermotherapy for routine treatment. The 08/20/26 annual review kept the policy intent unchanged, and the current effective date is August 20, 2026.
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 Mississippi · Effective Jan 1, 2026Medium impact
Magnetic Resonance Imaging-Targeted Biopsy of the Prostate
BCBSMS policy L.7.01.448 states that magnetic resonance imaging-targeted biopsy of the prostate may be considered medically necessary for diagnosis and active surveillance of prostate cancer. Effective 01/01/2026, the Code Reference section adds new CPT codes 55708, 55710, 55711, 55712, 55713, 55714 and 55715 for MRI-fusion and in-bore CT- or MRI-guided prostate biopsy.
Aetna · Identified Oct 1, 2026Medium impact
Prostate Cancer Screening (CPB 0521, reviewed 2026-08-28)
Aetna's Clinical Policy Bulletin 0521 covers prostate cancer screening. PSA screening is medically necessary as a preventive service for average-risk men 45 years of age and older, and for high-risk men 40 years of age and older, including African-American men and men with a family history of prostate cancer. Routine screening for members 75 years of age or older is not medically necessary unless life expectancy is 10 years or more, and tests such as Stockholm3, the Apifiny non-PSA blood test and the EpiSwitch Prostate Screening Test are considered experimental, investigational or unproven for prostate cancer screening.
Healthfirst · Identified Sep 2, 2026Medium impact
Prostate Cancer Awareness Month (Sept 2026): Documentation and Coding Resources for Your Practice
Healthfirst has released updated documentation and coding guidance for prostate cancer diagnosis coding to improve accuracy and specificity. The resource provides ICD-10-CM code selection rules, documentation requirements, and examples for active treatment, surveillance, and metastatic cases to ensure proper claim submission to Healthfirst.
Aetna · Identified Aug 18, 2026Medium impact
Urinary Incontinence (CPB 0223, reviewed 2026-07-16)
Aetna Clinical Policy Bulletin 0223 on urinary incontinence, reviewed 2026-07-16, considers multi-channel urodynamic studies medically necessary when a member has both symptoms and physical findings of urinary incontinence or voiding dysfunction and the provider is considering invasive, potentially morbid or irreversible treatment after conservative management has failed. It considers medically necessary the artificial urinary sphincter, FDA-cleared peri-urethral bulking agents, permanent sacral nerve stimulators after temporary trial stimulation, percutaneous tibial nerve stimulation, weighted vaginal cones, pessaries, tension-free and transobturator tape procedures, colposuspension and sub-urethral sling procedures when the stated criteria are met. Bilateral permanent sacral nerve stimulator implantation, the Genityte and FemiLift laser procedures, stem cell therapy and many other listed interventions are considered experimental, investigational or unproven.
Aetna · Identified Aug 18, 2026Medium impact
Testosterone Cypionate Injections (CPB 1014, reviewed 2026-07-13)
Aetna's clinical policy for testosterone cypionate injection (Azmiro, Depo-Testosterone or generic formulation) covers it for commercial medical plans when it is medically necessary for primary or hypogonadotropic hypogonadism, or for gender dysphoria when prescribed for gender-affirming care, under the listed criteria. For hypogonadism, the member must have at least two confirmed low morning testosterone levels before therapy starts. Continuation for hypogonadism requires a confirmed low morning testosterone level before the start of therapy. Aetna considers age-related or late-onset hypogonadism, female sexual dysfunction or hypoactive sexual desire disorder, heart failure, menopause, hormonal replacement in prostate cancer survivors with testosterone deficiency, and improvement of cognitive function in aging men experimental, investigational, or unproven.
Aetna · Identified Aug 16, 2026Medium impact
Sipuleucel-T (Provenge) (CPB 0802, reviewed 2025-12-22)
Aetna's Clinical Policy Bulletin 0802 covers sipuleucel-T (Provenge) for commercial medical plans, and Medicare criteria are in a separate policy. Aetna considers one course of sipuleucel-T, a total of 3 doses, medically necessary for metastatic castrate-resistant (hormone-refractory) prostate cancer in members who are asymptomatic or minimally symptomatic, have ECOG performance status 0 or 1, and do not have liver metastases, and therapy is limited to one course. Aetna considers all other indications experimental, investigational, or unproven, including prevention of prostate cancer, stage I to III prostate cancer, localized prostate cancer, and administration of more than 3 complete doses.
Aetna · Identified Aug 14, 2026Medium impact
Tumor Scintigraphy (CPB 0168, reviewed 2026-03-27)
Aetna considers ProstaScint medically necessary for pre-operative staging of newly diagnosed, biopsy-proven prostate cancer thought to be clinically localized with a moderate to high probability of occult extra-prostatic metastasis, and for staging after prostatectomy or radiation therapy when there is high suspicion of residual cancer or recurrence. The policy also covers Oncoscint for occult colorectal carcinoma and recurrent ovarian cancer, CEA-Scan with CT for recurrent or metastatic colorectal cancer, OctreoScan for neuroendocrine tumors bearing somatostatin receptors, I-131 MIBG imaging and therapy for neuroblastoma and pheochromocytoma or paraganglioma, lymphoscintigraphy with sentinel lymph node biopsy for the cancers it lists, and Lymphoseek (technetium Tc 99m tilmanocept) for locating lymph nodes in members with breast cancer or melanoma who are undergoing surgery to remove tumor-draining lymph nodes. Azedra (iobenguane I-131) is considered medically necessary for adults and adolescents aged 12 years and older with unresectable pheochromocytoma or paraganglioma that has spread beyond the original tumor site and requires systemic anti-cancer therapy. For all other indications, the policy considers these procedures experimental, investigational, or unproven.
Aetna · Identified Aug 14, 2026Medium impact
Prostate Cancer Screening (CPB 0521, reviewed 2025-11-25)
Aetna considers PSA screening medically necessary as a preventive service for men 45 years of age and older who are average risk and men 40 years of age and older who are high risk, including African-American men and men with a family history of prostate cancer. Routine prostate cancer screening for members 75 years of age or older is considered not medically necessary unless life expectancy is greater than or equal to 10 years, and annual digital rectal examination (DRE) is covered as a service. Several blood, urine and tissue tests, including PCA3, Stockholm3, ProstateNext, the four-kallikrein panel and selenium measurement, are considered experimental, investigational, or unproven for prostate cancer screening, and the CPT codes listed as not covered apply to the indications in the policy.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Whole Gland Cryoablation of Prostate Cancer
Whole gland cryoablation of the prostate may be considered medically necessary as treatment of clinically localized (organ-confined) prostate cancer. This applies when it is performed as initial treatment or as salvage treatment of disease that recurs following radiotherapy. Subtotal (focal) cryoablation is addressed in the Focal Treatments for Prostate Cancer medical policy.

Watch Z85.46

Get one email when a payer policy names Z85.46, a payer adds or drops it from a prior auth list, or Medicare changes its NCCI pairs, unit limit, payment or coverage articles.

No account needed. We send a confirmation link first, and every email has a one-click stop link.

FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code Z85.46?

There are 18 tracked policy changes affecting code Z85.46, including updates from Excellus BlueCross BlueShield, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of North Dakota. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code Z85.46?

Payers that have issued tracked updates for code Z85.46 include: Excellus BlueCross BlueShield, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of North Dakota, Aetna, Healthfirst.

How do I get notified when code Z85.46 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code Z85.46. 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 Z85.46?

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

Get alerts for changes like this

Save a search and get email alerts when a new policy change matches your filters: daily or weekly, your choice, on every plan.

Create a free alert How Policy Monitoring works

Magnetic Resonance Imaging (MRI) of the Prostate - (Effective Date - 2026-10-15) 6.01.46

Prostate Specific Antigen (PSA)

Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)

Radiopharmaceuticals for the Treatment of Cancer 6.01.44

Radiopharmaceuticals for the Treatment of Cancer 6.01.44

Laboratory Testing for the Screening and Management of Prostate Cancer 2.02.48

Pharmacy Policies Available Online

Focal Therapies for Prostate Cancer Treatment 7.01.01

Germline Genetic Testing for Hereditary Cancers 2.02.60

Magnetic Resonance Imaging-Targeted Biopsy of the Prostate

Prostate Cancer Screening (CPB 0521, reviewed 2026-08-28)

Prostate Cancer Awareness Month (Sept 2026): Documentation and Coding Resources for Your Practice

Urinary Incontinence (CPB 0223, reviewed 2026-07-16)

Testosterone Cypionate Injections (CPB 1014, reviewed 2026-07-13)

Sipuleucel-T (Provenge) (CPB 0802, reviewed 2025-12-22)

Tumor Scintigraphy (CPB 0168, reviewed 2026-03-27)

Prostate Cancer Screening (CPB 0521, reviewed 2025-11-25)

Whole Gland Cryoablation of Prostate Cancer

What insurance policy changes affect code Z85.46?

Which payers have updated policy for code Z85.46?

How do I get notified when code Z85.46 policy changes?

Why do payers change policies for code Z85.46?