CommercialCoverageHigh impact
Medical Policy and Coding Updates - July 2023
Premera Blue Cross·WA · Orthopedics, Cardiology, Oncology +6 more·Medical Policy
Effective date
Jul 1, 2023
We identified it
Jun 18, 2026
Summary
Premera Blue Cross has implemented multiple policy updates affecting various medical specialties, with new coverage for Zilretta knee injections (once per lifetime per knee), updated psychiatric evaluation requirements for behavioral health admissions, and several new drug approvals with specific medical necessity criteria. Changes include new investigational designations, revised prior authorization requirements, and updated documentation standards across medical, surgical, and pharmacy policies.
Action Required
By September 1, 2023: Billing team must update systems to reflect new Zilretta coverage limitations (once per knee per lifetime for moderate to severe osteoarthritis). By August 4, 2023: Update oncology drug coverage for Xgeva. By August 1, 2023: Ensure psychiatric evaluation documentation occurs within one day after admission (not within one day of admission) and add nursing assessment requirements upon admission for behavioral health claims. Providers must verify all new drug approvals meet specific medical necessity criteria before prescribing. Update encounter forms and billing software to reflect investigational status changes for multiple procedures and drugs.