Back to dashboard
Medicare AdvantagePrior AuthHigh impact

Medical policy updates

Blue Cross Blue Shield of Rhode Island·RI · Neurosurgery, Orthopedics, Cardiology +4 more·Physician / Facility
Effective date
Sep 1, 2026
We identified it
Jul 1, 2026
Days to comply
62 days

Summary

Effective September 1, 2026, this comprehensive medical policy update introduces new prior authorization requirements for 29 spinal procedure CPT codes, three additional CPT codes (33285, 93228, 93229), and multiple genetic/biomarker testing codes across Medicare Advantage and/or commercial plans. Additionally, new ICD-10 diagnosis codes for Parkinson Disease chelation therapy, revised medical necessity criteria for multiple procedures, and significant reorganization of biomarker testing criteria into a centralized mandate policy will require billing system updates and provider notification.

Action Required

Before Sep 1, 2026
By August 15, 2026: Billing team must complete the following: (1) Update billing software to require prior authorization through the spine procedures vendor for 29 additional spinal procedure CPT codes for Medicare Advantage plans; (2) Add prior authorization requirements in the online authorization tool for CPT codes 33285, 93228, 93229, 81503, and 69930 per plan type specifications; (3) Configure system to flag CPT codes 0388U, 81504, and 0528U for prior authorization and direct providers to the online authorization tool; (4) Revise medical necessity criteria in billing system for CPT codes 69705, 69706, 0214U, and 0215U; (5) Remove CPT codes 0045U, 0425U, and 0426U from their respective policies and route to Biomarker Testing Mandate criteria; (6) Add ICD-10 diagnosis codes G20.A1, G20.A2, G20.B1, G20.C, G21.4, G21.8, G21.9 to chelation therapy coverage for off-label Parkinson Disease treatment; (7) Update coverage status for CPT codes 81171, 81172, 81174, 81337, 81362 (MA plans: not covered; commercial: update criteria), and 81443, 0129U (covered for both); (8) Update medical necessity criteria for CPT codes 81190, 81221, 0583U, 81289; (9) Update encounter forms and provider alerts to reflect all changes; (10) Notify providers of these changes, particularly those performing spine procedures, genetic testing, biomarker testing, and cochlear implants. Failure to implement prior authorization requirements will result in claim denials. Update must be completed by system go-live date of September 1, 2026.

Affected Billing Codes

33285
93228
93229
81503
69930
69705
69706
81171
81172
81174
81337
81362
81190
81221
81289
81443
81504
G20.A1
G20.A2
G20.B1
G20.C
G21.4
G21.8
G21.9