Medicare AdvantagePrior AuthHigh impact
Medical policy updates
Blue Cross Blue Shield of Rhode Island·RI · Pulmonology, Psychiatry, Orthopedics +3 more·Physician / Facility
Effective date
Nov 1, 2026
We identified it
Sep 1, 2026
Summary
This policy update consolidates multiple medical policies effective November 1, 2026, with key changes including: (1) molecular testing codes for pulmonary nodules moving to a separate biomarker policy with no coverage changes; (2) genetic testing for mental health conditions replacing an obsolete test with OptimalRx Plus (not covered for Medicare Advantage, not medically necessary for commercial); (3) shoulder joint replacement requiring prior authorization with revised medical criteria; (4) ProMark Risk Score policy consolidation with no coverage changes; and (5) removal of prior authorization for in-lab sleep studies (CPT 95805, 95808, 95810, 95811) for commercial products effective October 1, 2026. Additionally, Medicare Advantage coverage is now subject to change at Medicare's discretion for LTACH admissions.
Action Required
IMMEDIATE ACTIONS REQUIRED - Multiple effective dates:
By October 1, 2026: Billing team must remove prior authorization requirements for in-lab sleep studies (CPT 95805, 95808, 95810, 95811) in the billing system for Commercial Products only. Update encounter forms and authorization workflows to reflect that these codes no longer require prior auth for commercial plans.
By November 1, 2026: (1) Billing team must update system rules to redirect molecular testing codes 0360U, 0080U, 0092U, and 81479 (Percepta Bronchial Genomic Classifier) to reference the new Biomarker Testing Mandate policy instead of the pulmonary nodules policy - no coverage changes but system logic must be updated. (2) Update shoulder replacement authorization logic: Prior authorization remains required for CPT 23470 and 23472 for Medicare Advantage plans and is recommended for Commercial Products, but system must use REVISED medical criteria from the new policy instead of existing authorization tool criteria. (3) For genetic testing (CPT 81479): Remove obsolete Genecept Assay and add OptimalRx Plus (Dynacare Plus) to system. Flag as NOT COVERED for Medicare Advantage and NOT MEDICALLY NECESSARY for commercial - claims should be denied accordingly. (4) Consolidate ProMark Risk Score policy (CPT 81479) in system with no coverage changes. (5) Update Medicare Advantage policy language for LTACH admissions to reflect that coverage may change per Medicare determination.
Providers must be notified: Prior authorization requirements changed for shoulder procedures (23470, 23472) with new medical criteria - training required. Sleep study prior auth removed for commercial (95805, 95808, 95810, 95811). OptimalRx Plus is now covered test but with restrictions by plan type.
Consequences of inaction: Claims for shoulder procedures using old criteria will be denied; sleep study claims will be denied if prior auth is obtained unnecessarily for commercial; OptimalRx Plus claims without proper coverage determination will be denied; claims for displaced molecular testing codes may be delayed or denied if not properly redirected.