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Medical Policy and Coding Updates - August 2025
Effective date
Not stated in the notice
Identified
Jun 16, 2026
Summary
Effective January 1, 2026, site of service is reviewed for advanced imaging services under Carelon Medical Benefits Management's Site of Care for Advanced Imaging criteria, and hospital outpatient site of care is considered medically necessary when ancillary services are required and not available at freestanding centers in the same geographic area. Effective November 7, 2025, bariatric surgery reoperation for inadequate weight loss is considered medically necessary if the original procedure fails, such as unsuccessful band adjustments, resulting in less than 50% excess weight loss or less than 20% total weight loss. Effective November 7, 2025, select surgical procedures previously reviewed for site of service in the inpatient setting are reviewed for site of service in the ambulatory surgical center setting under policy 11.01.525.
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What to do
Action · 7 steps
01Already effective January 1, 2026: Advanced imaging site of service is reviewed under the Carelon Site of Care for Advanced Imaging criteria.
02Hospital outpatient site of care is considered medically necessary when ancillary services are required and not available at freestanding centers in the same geographic area, and when specialized resources are needed and not available or infrequently performed at freestanding centers in the same area.
03Already effective November 7, 2025: Bariatric surgery reoperation is medically necessary when the original procedure fails, as described in the policy.
04Select surgical procedures listed under policy 11.01.525 are reviewed for site of service in the ambulatory surgical center setting.
05An elective surgical procedure performed in a hospital outpatient department may be considered medically necessary if there is no access to an ambulatory surgical center when criteria are met.
06Already effective November 15, 2025: Carelon Radiology Benefit Management Program codes 95965 and 95966 are reviewed by Carelon Specialty Health for medical necessity and prior authorization.
07Already effective October 3, 2025: For the drug codes now requiring site of service review, such as J0491, J9332, J9334, J3032, J3241, J0517, J2182, J9024, J9272, J9622, J0638, J2351, J3111, J2356 and J2357, site of service applies in addition to medical necessity and prior authorization review.
Codes mentioned
9596595966A4544E0743921339213492137J9120J9172Q2050J9246J2425J9200J9295J9017J9033C9600C9601C9602C96039292092921929249292592928929299293392934929379293892941929439294492980929821931827412274152741628446298662986729871298732987429875298762987729879298802988129882298832988429888298893040030410304203043030435304503123331235312403125331254312553125631257312593126731276312873128831295312963129731298421456365063655636616366263663636646368563688J7330S2112277002770227703C1721C1722C1824C1882C1895C1896C18993321633217332303323133240332493327033271932609328793289J0364J1748C9739C97405244152442J3111J0517J0638J9173J9272J2182J2351J9622J0491J9022J9024J3241J2356J3032J9332J9334J2357J1747C1763S0145J0248J1201J2278J3396L6882Q5151Q5152J08933823038240E0637
Original notice
Medical Policy and Coding Updates - August 2025
premera.com · Always check the source before changing claims.
Related changes
See all Premera Blue Cross changes →Medical Policy and Coding Updates - September 2025HighEffective Jan 1, 2026 · Medical PolicyMedical Policy and Coding Updates - October 2025HighEffective Jan 2, 2026 · Medical PolicyMedical Policy and Coding Updates - November 2025HighEffective Feb 6, 2026 · Medical PolicyMedical Policy and Coding Updates - July 2025HighNo effective date · Medical PolicyBrowse every Premera Blue Cross change in the policy list
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