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Premera Blue CrossCommercial · Coverage · Medical Policy · WA · Orthopedics, Pain Management, Oncology +2 moreMedium impact

Medical Policy and Coding Updates - July 2023

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

Summary

Effective September 1, 2023, Premera HMO added Zilretta (triamcinolone acetonide extended-release injectable suspension) as medically necessary for moderate to severe osteoarthritis pain of the knee in adults, approved once per knee per lifetime, and considers it investigational for all other indications. Effective August 4, 2023, Xgeva (denosumab) was added for the prevention of skeletal-related events in individuals with bone metastases from solid tumors and in individuals with multiple myeloma. Effective July 1, 2023, Premera HMO added medical necessity criteria for Veozah and Elfabrio, expanded Sotyktu trial and failure criteria to three of the listed agents, and made maternal serum biomarker tests for preeclampsia or spontaneous preterm birth investigational.

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What to do

Action · 3 steps
01Already effective September 1, 2023: Zilretta is medically necessary for knee osteoarthritis pain in adults when criteria are met, with approval allowed once per knee per lifetime, and all other indications are investigational.
02Already effective August 4, 2023: Xgeva was added for prevention of skeletal-related events in bone metastases from solid tumors and in multiple myeloma.
03Already effective July 1, 2023: Codes C9146, C9147, C9148 and C9149 are listed as terminated, and codes J9063, J9322, J9323, J9347, J1576, J9380, J9350, J1961, J9029 and J1440 now require review for medical necessity and prior authorization, so obtain prior authorization for these codes.

Codes mentioned

C9146C9147C9148C9149J9063J9322J9323J9347J1576J9380J9350J1961J9029J1440

Original notice

Medical Policy and Coding Updates - July 2023
premera.com · Always check the source before changing claims.
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Related changes

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Related policy hubs

Premera Blue Cross policiesWA policy changesOrthopedicsPain ManagementOncologyPharmacyCardiothoracic SurgeryCode C9146Code C9147Code C9148Code C9149Code J9063Code J9322Code J9323Code J9347Code J1576Code J9380Code J9350Code J1961Code J9029Code J1440

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