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Premera Blue CrossCommercial · Prior Auth · Medical Policy · WA · Orthopedics, Pain Management, Cardiology +8 moreMedium impact

Medical Policy and Coding Updates - January 2024

Effective date
Not stated in the notice
Identified
Jun 18, 2026

Summary

Effective April 14, 2024, Carelon Radiation Therapy Clinical Appropriateness Guidelines add intensity-modulated radiation therapy for the adjuvant treatment of locally advanced adenocarcinoma of the cecum, add stereotactic body radiotherapy for hepatocellular carcinoma, and adjust external beam radiation or IMRT for prostate cancer to 2 Gy fractions. Effective April 14, 2024, Carelon Advanced Imaging Clinical Appropriateness Guidelines add several indications, including annual surveillance in Caroli disease and syndrome, MRI for suspected pelvic organ prolapse, and chest CT for planning biopsy or fiducial marker placement with navigational bronchoscopy, and remove routine preoperative FDG-PET/CT for biliary tract cancers. Effective January 1, 2024, Premera HMO added a High-Risk Conditions (Oral Health) Dental Benefit policy 10.01.535, and removed criteria for Applied Behavior Analysis that are no longer used for medical necessity or coverage determinations.

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What to do

Action · 7 steps
01Already effective January 1, 2024: Codes 75580, 81457, 81458, 81459, 81462, 81463, 81464, 0420U and 0422U for Carelon genetic testing now require review for medical necessity and prior authorization, so obtain prior authorization for these codes, and code 27278 for sacroiliac joint pain now requires review for investigational status.
02Already effective January 1, 2024: Code C9157 for ALS medications and codes 0775T and 0809T for sacroiliac joint pain are terminated.
03Already effective January 1, 2024: Coronary angiography codes C7557 and C7558 now require review for medical necessity.
04Already effective January 1, 2024: Immune checkpoint inhibitor code J9258 and C3 and C5 complement inhibitor code C9162 now require review for medical necessity and prior authorization.
05Already effective April 14, 2024: Carelon Advanced Imaging and Radiation Therapy guideline changes apply to dates of service on and after April 14, 2024.
06Already effective April 4, 2024: Rituxan Hycela (rituximab and hyaluronidase) requires documentation of CD20 antigen expression.
07Already effective April 4, 2024: Maintenance transcranial magnetic stimulation is not medically necessary if the preceding course of intensive TMS was not medically necessary, and a repeat full intensive course or a short or brief intensive course is not medically necessary when the preceding course was not medically necessary.

Codes mentioned

7558081457814588145981462814638146427278C9157C7557C7558J9258C9162

Original notice

Medical Policy and Coding Updates - January 2024
premera.com · Always check the source before changing claims.
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Related changes

See all Premera Blue Cross changes →
Medical Policy and Coding Updates - October 2023MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - April 2024MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - May 2024MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - January 2025HighNo effective date · Medical PolicyBrowse every Premera Blue Cross change in the policy list

Related policy hubs

Premera Blue Cross policiesWA policy changesOrthopedicsPain ManagementCardiologyGeneticsOncologyRadiation OncologyRadiologyDentistryNeurologyRheumatologyGastroenterologyCode 75580Code 81457Code 81458Code 81459Code 81462Code 81463Code 81464Code 27278Code C9157Code C7557Code C7558Code J9258Code C9162

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