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Medical Policy and Coding Updates - September 2025
Premera Blue Cross·WA · Radiology, Diagnostic Imaging, Neurology +5 more·Medical Policy
Effective date
Nov 15, 2025
We identified it
Jun 16, 2026
Summary
Premera Blue Cross updated multiple policies effective November 15, 2025 through January 1, 2026, including new site of care reviews for advanced imaging through Carelon Medical Benefits Management, updated botulinum toxin criteria, and new coverage for negative pressure wound therapy devices. The changes also include extensive updates to radiology appropriateness guidelines across multiple imaging categories.
Action Required
By November 15, 2025: Billing team must ensure all advanced imaging services meet new site of care criteria administered through Carelon Medical Benefits Management. Contact Carelon at MedicalBenefitsManagement.guidelines@Carelon.com for questions. By December 4, 2025: Update botulinum toxin authorization processes to reflect that concurrent use of different botulinum toxin products is not allowed. By January 1, 2026: Implement new site of service review requirements for all advanced imaging - claims may be denied if performed at hospital outpatient departments without meeting medical necessity criteria.