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Premera Blue CrossCommercial · Billing Codes · Medical Policy · WA, AK · Oncology, Hematology, Ophthalmology +10 moreMedium impact

Medical Policy and Coding Updates - April 2023

Effective date
Jul 6, 2023
Identified
Jun 18, 2026

Summary

Codes J0218, J1747, J9294, J9296, J9297, Q5127, Q5128, Q5129, Q5130 and Carelon genetic testing codes 0364U, 0368U, 0378U, 0379U and 0380U now require medical necessity review and prior authorization effective April 1, 2023. Codes A2019 through A2021, Q4265 through Q4271 and several others now require investigational review, and C9757 for lumbar spine decompression no longer requires medical necessity review but now requires investigational review. The update also added Syfovre for geographic atrophy, Filspari for IgA nephropathy and Orserdu for ESR1-mutated breast cancer.

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What to do

Action · 6 steps
01Already effective April 1, 2023: Medical necessity and prior authorization review applies to J0218, J1747, J9294, J9296, J9297, Q5127, Q5128, Q5129, Q5130, and Carelon genetic testing codes 0364U, 0368U, 0378U, 0379U and 0380U.
02Billing team: confirm prior authorization is in place for these codes before billing them.
03Already effective April 1, 2023: Medical necessity review applies to C9146, C9147, C9148 and C9149.
04Investigational review applies to A2019, A2020, A2021, Q4265 through Q4271, A7049, E0677, 0365U, 0366U, 0367U, 0375U, 0376U, E1905 and C9757.
05Already effective April 1, 2023: S2067 and S2068 no longer require review for medical necessity, and 0207T, 0330T, 0507T and 0563T no longer require review.
06Check current applicability of these dates before acting on them.

Codes mentioned

Q4265Q4266Q4267Q4268Q4269Q4270Q4271C9146A2019A2020A2021J0218J9294J9296J9297C9147Q5129Q5128C9148A7049E0677J1747C9149E1905Q5127Q5130C9757S2067S2068

Original notice

Medical Policy and Coding Updates - April 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 2023MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - June 2018MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - October 2025HighEffective Jan 2, 2026 · Medical PolicyMedical Policy and Coding Updates - September 2021MediumNo effective date · Medical PolicyBrowse every Premera Blue Cross change in the policy list

Related policy hubs

Premera Blue Cross policiesWA policy changesAK policy changesOncologyHematologyOphthalmologyWound CareRheumatologyEndocrinologyNephrologyGeneticsNeurologyOrthopedicsPharmacyPlastic SurgeryDermatologyCode Q4265Code Q4266Code Q4267Code Q4268Code Q4269Code Q4270Code Q4271Code C9146Code A2019Code A2020Code A2021Code J0218Code J9294Code J9296Code J9297Code C9147Code Q5129Code Q5128Code C9148Code A7049Code E0677Code J1747Code C9149Code E1905Code Q5127Code Q5130Code C9757Code S2067Code S2068

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