CommercialBilling CodesHigh impact
2025 November Medical Policy Updates
BlueCross BlueShield of South Carolina·SC · Infectious Disease, Internal Medicine, Family Medicine +12 more·Medical Policy
Effective date
Nov 1, 2025
We identified it
Aug 11, 2026
Summary
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan released 33 medical policy updates and revisions effective November 2025. Key changes include: new psychological/neuropsychological testing policy (CAM 397), extended lumbar fusion revision surgery timeline (9-12 months vs 6-12 months), expanded HIV testing coverage with PrEP criteria, negative pressure wound therapy trial period extended from 14 to 30 days, multiple CPT code additions/removals in sexual health and infectious disease testing, and new minimal residual disease coverage for diffuse large B-cell lymphoma. Billing teams must immediately update claim submission rules, prior authorization triggers, and CPT code billing matrices across multiple service lines.
Action Required
IMMEDIATE (by December 10, 2025): Billing team must execute the following: (1) REMOVE from billing system and deny claims: CPT codes 82565, 82575, 84703, 86701-86705, 86803-86804, 87660, 0500T, G0432, G0433, G0435, G0475, S3645 for BlueCross BlueShield of South Carolina and BlueChoice plans - these are no longer covered for sexually transmitted infection testing per CAM 209 and CAM 282. (2) ADD to active billing codes: CPT 87626 and 87800 (STI testing per CAM 209) and CPT 87164, 87166 (vector-borne infection testing per CAM 210). (3) Update billing software to REMOVE CPT 87631 (influenza testing per CAM 134). (4) Create hard-stop flag in billing system: any claim with removed codes must be rejected with reason code indicating policy change. (5) For HIV testing (CAM 282): Configure system to REQUIRE documentation of HIV risk factors (new Note 2) before claim submission; add PrEP coverage criteria to prior auth decision tree. (6) For negative pressure wound therapy (CAM 10116): Update initial trial authorization from 14 days to 30 days in prior auth module. (7) For lumbar spine fusion (CAM 161): Modify prior auth logic to require 9-12 month documentation of prior operation (changed from 6-12 months) before approving revision surgery. (8) Create new policy record for CAM 397 (psychological/neuropsychological testing) in billing system with coverage/non-coverage flags. (9) Provider/front desk staff: Update encounter forms and templates to capture HIV risk factors and ensure 30-day negative pressure wound therapy trial documentation. (10) Consequences: Claims submitted with deleted codes will be denied; claims without proper documentation for HIV risk factors will be pended; revision surgery approvals may be delayed if documentation doesn't meet new 9-12 month threshold. Notify all providers and referral coordinators of CPT code changes immediately via staff communication.