Premera Blue CrossCommercial · Coverage · Medical Policy · WA · Dermatology, Neurology, ENT (Ear, Nose & Throat) +7 moreMedium impact
Medical Policy and Coding Updates - November 2023
Effective date
Not stated in the notice
Identified
Jun 18, 2026
Summary
Effective November 1, 2023, Premera HMO added Botox (onabotulinumtoxinA) for primary focal axillary or palmar hyperhidrosis in adults, moving that criteria from the Treatment of Hyperhidrosis policy, and added Daxxify (daxibotulinumtoxinA-lanm) for cervical dystonia in adult individuals. Effective November 1, 2023, the hypoglossal nerve stimulation criteria for adults with obstructive sleep apnea increased the body mass index limit from 32 kg/m2 to 40 kg/m2, and concurrent use of Beyfortus (nirsevimab-alip) and Synagis (palivizumab) within the same respiratory syncytial virus season was considered not medically necessary. Effective November 1, 2023, Premera HMO added Lumryz (sodium oxybate) for cataplexy or excessive daytime sleepiness in adults with narcolepsy, and required documentation confirming the diagnosis for Actemra (tocilizumab) when used for cytokine release syndrome.
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01Already effective November 1, 2023: Codes 11450, 11451 and 69676 for surgical treatment of hyperhidrosis now require review for medical necessity and prior authorization.
02Already effective November 1, 2023: Code C9789 under non-covered experimental or investigational services now requires review for investigational status.
03Already effective November 1, 2023: Code K1027 under non-covered services and procedures is now reviewed by Carelon Medical Benefits Management for medical necessity and prior authorization.
04Already effective November 1, 2023: Codes A9291 and 98978 for prescription digital therapeutics for substance use disorders no longer require review.
05Already effective November 1, 2023: Use generic lisdexamfetamine dimesylate before brand Vyvanse for attention deficit hyperactive disorder, and Actemra for cytokine release syndrome requires documentation confirming the diagnosis.
Codes mentioned
114501145169676C9789K1027A929198978
Original notice
Medical Policy and Coding Updates - November 2023
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