Summary
This comprehensive policy update effective October 1, 2026, modifies coverage, prior authorization requirements, and billing procedures across 9 different medical services. Changes vary significantly by plan type (Medicare Advantage vs. Commercial), with some services moving from covered to non-covered, others gaining prior authorization requirements, and several undergoing administrative restructuring. Billing teams must implement plan-specific workflows immediately to avoid claim denials after the effective date.
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What to do
Action · 17 steps
01DEADLINE: By September 30, 2026, billing team must implement the following plan-specific changes in the billing system:
MAXIMUM PRIORITY - Coverage Changes (affects claims processing):
1.
02Medicare Advantage: STOP billing for Interferential Current Stimulation (move to denial rules)
2.
03Commercial: Add prior authorization requirement for Enhanced External Counterpulsation (HCPCS G0166) using the EECP Medical Policy criteria
3.
04Medicare Advantage: Flag CPT codes for Removal of Implantable Devices to REMOVE prior authorization requirement
4.
05Commercial: REMOVE prior authorization requirement for Removal of Implantable Devices CPT codes
5.
06Medicare Advantage: Update Renal Denervation for Uncontrolled Hypertension from 'not covered' to 'follow CMS National and Local Coverage Determinations'; Commercial: Add prior authorization recommendation using policy medical criteria
6.
07Medicare Advantage: Update CPT 0935T from prior authorization to 'follow CMS National and Local Coverage Determinations'
MEDIUM PRIORITY - Prior Authorization & Documentation Changes:
1.
08Commercial: Update medical criteria for Epidural Injections for Pain Management in online authorization tool; archive old policy
2.
09Commercial: Revise medical criteria for Microvolt T-Wave Alternans Testing in authorization tool
3.
10Billing team: For HCPCS codes J7311, J7312, J7313, J7314, J1096, and 68841 (Intravitreal and Punctum Corticosteroid Implants), REMOVE diagnosis edits from this policy and apply Pharmacy-Post Claim Review Medications Payment Policy rules instead
LOW PRIORITY - Administrative Updates:
1.
11Medicare Advantage: Update Glucose Monitoring brand preference from One Touch to Abbott in system; combine Continuous and Home monitoring policies into single 'Glucose Monitoring Devices and Supplies' policy
2.
12Update internal policy records to reflect renamed policies: Maternal Serum Testing (formerly Biomarkers) and Renal Denervation (formerly Radiofrequency Ablation)
WHO: Billing team lead must coordinate with EMR/billing software vendor and medical coding team.
13Providers should be notified of prior authorization requirement changes.
14Front desk staff should update patient financial counseling scripts for affected services.
15WHERE: Update all rules in billing software, prior authorization system, claim submission workflows, and EMR templates.
16CONSEQUENCES: Failure to implement plan-specific rules will result in claim denials for Interferential Current Stimulation (MA), missing prior auth denials for Enhanced External Counterpulsation (Commercial), and payment complications for implant removals and renal denervation procedures.
17Diagnosis edit removal for implant codes will require system reconfiguration or claims will be incorrectly flagged for review.
Codes mentioned
G0166J7311J7312J7313J7314J109668841
Original notice
Medical policy updates
bcbsri.com · Always check the source before changing claims.
Related changes
See all Blue Cross Blue Shield of Rhode Island changes →CPT code changesHighEffective Jan 1, 2022 · Physician / FacilityPolicy updatesMediumEffective Oct 1, 2023 · Physician / FacilityMedical policy updatesHighEffective Jan 1, 2027 · Physician / FacilityMedical policy updatesMediumEffective Dec 1, 2026 · Physician / FacilityBrowse every Blue Cross Blue Shield of Rhode Island change in the policy list