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Premera Blue CrossCommercial · Coverage · Medical Policy · WA · Orthopedics, Pain Management, ENT (Ear, Nose & Throat) +7 moreMedium impact

Medical Policy and Coding Updates - December 2023

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

Summary

Effective March 17, 2024, Carelon Medical Benefits Management Genetic Testing Clinical Appropriateness Guidelines (formerly AIM Specialty Health) replaced contraindicated with unsafe or infeasible for tissue biopsy in cell-free DNA testing, restricted somatic tumor testing to 50 genes or less for several cancers and leukemias, and removed the Afirma standalone assay for indeterminate thyroid nodules. Effective December 1, 2023, the Whole Body Dual X-Ray Absorptiometry and Bioelectrical Impedance Analysis to Determine Body Composition policy (6.01.528) states that whole-body dual energy X-ray absorptiometry or bioelectrical impedance analysis for body composition studies is investigational for all indications. Effective December 1, 2023, Premera HMO specified that inpatient mental health medical evaluations must be done by a physician, nurse practitioner, or physician assistant, or be done in an emergency department or hospital inpatient medical unit before direct transfer to the inpatient facility.

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What to do

Action · 6 steps
01Already effective December 1, 2023: Codes 20560 and 20561 for dry needling of trigger points for myofascial pain now require review for investigational status.
02Already effective December 1, 2023: Code 0358T for whole body dual energy X-ray absorptiometry now requires review for investigational status.
03Already effective December 1, 2023: Dry needling of trigger points for the treatment of myofascial pain is investigational.
04Already effective December 1, 2023: Whole body DXA and bioelectrical impedance body composition studies are investigational for all indications.
05Already effective March 7, 2024 for federal employee plans only: Anterior and posterior cervical fusion, cervical discectomy and cervical laminectomy may be considered medically necessary when criteria are met under policy 7.01.560, and lumbar spinal fusion is considered investigational for chronic nonspecific low back pain without radiculopathy, degenerative disc disease, disc herniation, facet syndrome, and initial discectomy or laminectomy for neural structure decompression.
06Already effective March 7, 2024: Zynteglo criteria require that the individual does not have an uncorrected bleeding disorder or history of advanced liver disease, is 50 years of age or younger, and is clinically stable and eligible to undergo a hematopoietic stem cell transplant.

Codes mentioned

2056020561Q5123

Original notice

Medical Policy and Coding Updates - December 2023
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 - January 2020MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - March 2020HighEffective Jun 5, 2020 · Medical PolicyMedical Policy and Coding Updates - July 2021MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - September 2023MediumNo effective date · Medical PolicyBrowse every Premera Blue Cross change in the policy list

Related policy hubs

Premera Blue Cross policiesWA policy changesOrthopedicsPain ManagementENT (Ear, Nose & Throat)GeneticsOncologyEndocrinologyPsychiatryPharmacyNeurosurgeryPediatricsCode 20560Code 20561Code Q5123

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