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Premera Blue CrossCommercial · Prior Auth · Medical Policy · WA, AK · Allergy & Immunology, Oncology, Rheumatology +14 moreHigh impact

Medical Policy and Coding Updates - February 2025

Effective date
Not stated in the notice
Identified
Jun 16, 2026

Summary

Premera's February 2025 update adds carpal tunnel release as a new surgical policy effective May 6, 2025, and changes IL-5 inhibitor and Dupixent asthma criteria, including the blood eosinophil count, which was lowered from 300 to 150 cells/mcL. It also moves Briumvi, Lemtrada, Ocrevus, Ocrevus Zunovo, Tyruko and Tysabri from the multiple sclerosis policy into a new Gene Therapies for Rare Diseases policy effective February 1, 2025, and removes site-of-service review from many infusion and biologic codes while keeping medical necessity and prior authorization review.

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What to do

Action · 6 steps
01Already effective February 1, 2025, February 7, 2025, March 5, 2025, April 6, 2025 and May 6, 2025, so check current applicability before acting on these past dates.
02Billing team: for Premera HMO members, J0850, J7351 and 90291 (Medical Necessity Criteria for Pharmacy Edits) and J9034, J9036, J9056, J9153, J9266 and J9268 (Miscellaneous Oncology Drugs) now require review for medical necessity and prior authorization, effective February 7, 2025.
03Billing team: for the codes listed under the February 1, 2025 revisions, including J0256, J0598, J2786, J9271 and J9299, site-of-service review no longer applies, but review for medical necessity and prior authorization is still required.
04Billing team: CAR-T codes 38225, 38226 and 38227 no longer require review, effective February 1, 2025.
05Billing team: under Gene Therapies for Rare Diseases (policy 5.01.644), effective February 1, 2025, in accordance with Alaska law (HB 226) site of service is not applicable to fully-insured members in Alaska, so refer to the infusion drug medical necessity criteria only.
06Billing team: carpal tunnel release is considered medically necessary for individuals with carpal tunnel syndrome who have failed conservative therapy when criteria are met, effective May 6, 2025.

Codes mentioned

J0850J735190291J9034J9036J9056J9153J9266J9268J0256J1300J1303J0180J0221J0584J1322J1458J1743J1786J1931J2840J3060J3385J3397J0598J2786J9271J9299J1459J1551J1552J1554J1555J1556J1557J1558J1559J1561J1566J1568J1569J1572J1575J1576J159990283J2323J2329J2350Q5134J0485J1426J1428J1429J1745J1747Q5103Q5104Q5121J0791J0129J1602J3247J3262Q5133J3380Q5115Q5119Q5123J2327J3358J0490J1823J931238225382263822792972

Original notice

Medical Policy and Coding Updates - February 2025
premera.com · Always check the source before changing claims.
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Related changes

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Medical Policy and Coding Updates - November 2025HighEffective Feb 6, 2026 · Medical PolicyMedical Policy and Coding Updates - December 2025HighNo effective date · Medical PolicyMedical Policy and Coding Updates - January 2026HighNo effective date · Medical PolicyMedical Policy and Coding Updates - February 2026HighNo effective date · Medical PolicyBrowse every Premera Blue Cross change in the policy list

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Premera Blue Cross policiesWA policy changesAK policy changesAllergy & ImmunologyOncologyRheumatologyPulmonologyGastroenterologyDermatologyNeurologyEndocrinologyCardiologyNephrologyHematologyOrthopedicsPlastic SurgeryUrologyOphthalmologyOB-GYNPharmacyCode J0850Code J7351Code 90291Code J9034Code J9036Code J9056Code J9153Code J9266Code J9268Code J0256Code J1300Code J1303Code J0180Code J0221Code J0584Code J1322Code J1458Code J1743Code J1786Code J1931Code J2840Code J3060Code J3385Code J3397Code J0598Code J2786Code J9271Code J9299Code J1459Code J1551Code J1552Code J1554Code J1555Code J1556Code J1557Code J1558Code J1559Code J1561Code J1566Code J1568Code J1569Code J1572Code J1575Code J1576Code J1599Code 90283Code J2323Code J2329Code J2350Code Q5134Code J0485Code J1426Code J1428Code J1429Code J1745Code J1747Code Q5103Code Q5104Code Q5121Code J0791Code J0129Code J1602Code J3247Code J3262Code Q5133Code J3380Code Q5115Code Q5119Code Q5123Code J2327Code J3358Code J0490Code J1823Code J9312Code 38225Code 38226Code 38227Code 92972

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