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Premera Blue CrossCommercial · Coverage · Medical Policy · WA · Endocrinology, Neurology, Hematology +5 moreMedium impact

Medical Policy and Coding Updates - October 2023

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

Summary

Effective October 1, 2023, Premera HMO added the Artificial Pancreas Device System with a closed-loop insulin delivery system (iLet Bionic pancreas), which may be considered medically necessary for individuals with type 1 diabetes, and made multimodal devices combining interferential current stimulation, neuromuscular electrical stimulation and transcutaneous electrical nerve stimulation investigational for all indications, including NexWave. Effective October 1, 2023, the gender transition and affirmation surgery policy added documentation that hair removal is intended to reduce gender dysphoria, changed the mental health recommendation timeframe from 6 to 12 months, and removed the prerequisite of hormone therapy for augmentation mammoplasty and genital surgeries. Effective October 1, 2023, Crysvita (burosumab) moved from the medical and pharmacy benefits to the medical benefit, and Elevidys (delandistrogene moxeparvovec-rokl) was added for ambulatory pediatric individuals aged 4 through 5 years with Duchenne muscular dystrophy and a confirmed DMD gene mutation.

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What to do

Action · 5 steps
01Already effective October 1, 2023: Codes A2022, A2023, A2024 and A2025 for bioengineered skin and soft tissue substitutes, and codes Q4285 and Q4286 for amniotic membrane, now require review for investigational status.
02Already effective October 1, 2023: Codes J2781 (C3 and C5 complement inhibitors), C9157 (ALS medications), J0801 and J0802 (repository corticotropin), and J1411 (hemophilia) now require review for medical necessity and prior authorization.
03Already effective October 1, 2023: Codes A9268, A9269, H2040, H2041 and V2526 are no longer covered under Non-covered Services and Procedures 10.01.517.
04Already effective October 1, 2023: Code 98978 for prescription digital therapeutics for substance use disorders no longer requires review, and codes 0357U, C9151, J0800 and 0397U are terminated.
05Already effective October 1, 2023: Crysvita is billed under the medical benefit, not the pharmacy benefit.

Codes mentioned

A2022A2023A2024A2025J2781C9157A9268A9269H2040H2041V252698978C9151J0800Q4285Q4286Q5123J0801J0802J1411A9292K1036

Original notice

Medical Policy and Coding Updates - October 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 - July 2021MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - January 2023MediumEffective Apr 9, 2023 · Medical PolicyMedical Policy and Coding Updates - September 2023MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - November 2023MediumNo effective date · Medical PolicyBrowse every Premera Blue Cross change in the policy list

Related policy hubs

Premera Blue Cross policiesWA policy changesEndocrinologyNeurologyHematologyOncologyRheumatologyPharmacyWound CarePain ManagementCode A2022Code A2023Code A2024Code A2025Code J2781Code C9157Code A9268Code A9269Code H2040Code H2041Code V2526Code 98978Code C9151Code J0800Code Q4285Code Q4286Code Q5123Code J0801Code J0802Code J1411Code A9292Code K1036

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