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Medical Policy and Coding Updates - December 2024
Effective date
Not stated in the notice
Identified
Jun 16, 2026
Summary
Premera's December 2024 medical policy and coding update adds medical necessity criteria for lymphedema and lipedema surgery, a new shoulder arthroplasty policy, and new or revised criteria for drugs including Ocrevus Zunovo, Dupixent, Ebglyss, Leqselvi and Wegovy. It also lists coding updates that require review for medical necessity and prior authorization, including cervical spine surgery codes 63001, 63015, 63040, 63050, 63051, 63075, 63081 and 63265, and it places infusion drugs such as Tyruko and Alyglo under site-of-service review.
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What to do
Action · 6 steps
01Already effective December 1, 2024, December 5, 2024, January 3, 2025, February 7, 2025 and March 5, 2025, so check current applicability before acting on these past dates.
02Billing team: for Premera HMO members, cervical spine surgery codes 63001, 63015, 63040, 63050, 63051, 63075, 63081 and 63265 now require review for medical necessity, including site of service, and prior authorization (effective December 5, 2024).
03Billing team: for Alyglo, Cosentyx IV, Spevigo IV, Tofidence IV and Tyruko, site of service will be reviewed (effective December 5, 2024).
04Billing team: code E0446 (hyperbaric oxygen therapy) now requires review for investigational (effective December 1, 2024).
05Billing team: codes 90901, 90912, 90913, 58353, 58356, 58563, 94774, 94775, 94776, 94777 and 64566 now require review for medical necessity and prior authorization (effective January 3, 2025).
06Billing team: the InterQual Criteria codes added effective December 1, 2024, including 23430, 25447 and 26055, now require review for medical necessity and prior authorization.
Codes mentioned
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
Original notice
Medical Policy and Coding Updates - December 2024
premera.com · Always check the source before changing claims.
Related changes
See all Premera Blue Cross changes →Medical Policy and Coding Updates - October 2024MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - November 2024HighNo effective date · Medical PolicyMedical Policy and Coding Updates - September 2019MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - January 2026HighNo effective date · Medical PolicyBrowse every Premera Blue Cross change in the policy list
Related policy hubs
Premera Blue Cross policiesWA policy changesAK policy changesAllergy & ImmunologyOncologyRheumatologyPulmonologyDermatologyNeurologyEndocrinologyGastroenterologyHematologyOrthopedicsPlastic SurgeryPharmacyUrologyOphthalmologySleep MedicineENT (Ear, Nose & Throat)Code 92972Code 63001Code 63015Code 63040Code 63050Code 63051Code 63075Code 63081Code 63265Code J1826Code J1830Code Q3027Code Q3028Code E0446Code M0224Code M0249Code M0250Code Q0224Code Q0249Code J1599Code J1747Code J3247Code Q5133Code Q5134Code A4575Code 29916Code A9590Code 23430Code 25447Code 26055Code 27427Code 28297Code 29806Code 29807Code 29822Code 29827Code 29828Code 30140Code 30520Code 33249Code 38525Code 45378Code 45380Code 45381Code 45385Code 45388Code 45390Code 45398Code 49650Code 55866Code 57425Code 58558Code 58661Code 58662Code 64718Code 93653Code 95716Code E0465Code E0784Code 90901Code 90912Code 90913Code A4606Code E0445Code 58353Code 58356Code 58563Code G0166Code 92132Code 92250Code 66174Code 66175Code 66183Code 46601Code 46607Code 94774Code 94775Code 94776Code 94777Code 93792Code 93793Code G0248Code G0249Code G0250Code 31513Code 31570Code 31571Code 31573Code 31574Code 76981Code 76982Code 76983Code 64566Code 66982Code 66983Code 66984Code V2630Code V2631Code V2632Code 90375Code 90376Code 90377Code 90675Code 90676Code 34701Code 34702Code 34703Code 34704Code 34705Code 34706Code 34707Code 34708Code 34709Code 34710Code 34711Code 34712Code 34713Code 34714Code 34715Code 34716Code 34808Code 34812Code 34813Code 34820Code 34833Code 34834Code 34841Code 34842Code 34843Code 34844Code 34845Code 34846Code 34847Code 34848Code 58720Code 58940Code A4633Code E0424Code E0431Code E0433Code E0434Code E0439Code E0441Code E0442Code E0443Code E0444Code E1390Code E1391Code E1392Code E1405Code E1406Code K0378Code 93668Code E0691Code E0692Code E0693Code E0694Code 95930