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Medical Policy and Coding Updates - April 2025
Effective date
Not stated in the notice
Identified
Jun 16, 2026
Summary
Physical and occupational therapy services for individual plans require prior authorization starting with the seventh visit, effective July 3, 2025. Humira (adalimumab) with NDCs starting with 00074 changed from a preferred to a non-preferred adalimumab product, effective July 1, 2025. Several codes now require medical necessity review or prior authorization, and Carelon genetic testing uses the sample or collection date as the date of service for dates of service on and after August 1, 2025.
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What to do
Action · 4 steps
01Already effective July 3, 2025: For individual plans, get prior authorization for physical and occupational therapy services starting with the seventh visit.
02The initial six visits do not require review, and these services continue to be reviewed using InterQual criteria.
03Already effective August 1, 2025: For Carelon genetic testing, the date of service is the sample or collection date, and for archival samples it is the sample collection or retrieval date.
04Providers may submit Carelon authorization requests through the Carelon provider portal, which is the fastest way to request an authorization.
Codes mentioned
J0175C9764C9767C7531C7534C7535A2035Q4354Q4355Q4356Q4357Q4358Q4359Q4360Q4361Q4362Q4363Q4364Q4365Q4366Q4367A2030A2031A2032A2033A2034J1299C9301J9161J9024J2351L5827C9303J9054Q2057L6700J9038C9304Q5148Q5147J2327J3358E0656E0657E0670E0912
Original notice
Medical Policy and Coding Updates - April 2025
premera.com · Always check the source before changing claims.
Related changes
See all Premera Blue Cross changes →Medical Policy and Coding Updates - October 2025HighEffective Jan 2, 2026 · Medical PolicyMedical Policy and Coding Updates - November 2021MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - February 2025HighNo effective date · Medical PolicyMedical Policy and Coding Updates - July 2025HighNo effective date · Medical PolicyBrowse every Premera Blue Cross change in the policy list
Related policy hubs
Premera Blue Cross policiesWA policy changesAK policy changesPhysical TherapyOccupational TherapyOrthopedicsRadiologyPharmacyDermatologyRheumatologyNeurologyOncologyGeneticsCardiologyPulmonologyGastroenterologyOB-GYNUrologyENT (Ear, Nose & Throat)HematologyEndocrinologyPediatricsCode J0175Code C9764Code C9767Code C7531Code C7534Code C7535Code A2035Code Q4354Code Q4355Code Q4356Code Q4357Code Q4358Code Q4359Code Q4360Code Q4361Code Q4362Code Q4363Code Q4364Code Q4365Code Q4366Code Q4367Code A2030Code A2031Code A2032Code A2033Code A2034Code J1299Code C9301Code J9161Code J9024Code J2351Code L5827Code C9303Code J9054Code Q2057Code L6700Code J9038Code C9304Code Q5148Code Q5147Code J2327Code J3358Code E0656Code E0657Code E0670Code E0912