CommercialCoverageHigh impact
Medical Policy and Coding Updates - April 2023
Premera Blue Cross·WA · Gastroenterology, Psychiatry, Radiology +3 more·Medical Policy
Effective date
Apr 9, 2023
We identified it
Jun 18, 2026
Summary
Multiple medical policy updates effective April-July 2023 including new coverage for C. difficile treatments (Rebyota, Zinplava), expanded ABA therapy criteria and provider types, updated radiology/cardiology imaging guidelines, and new radiation therapy indications. Most changes affect prior authorization requirements and coverage criteria.
Action Required
By July 6, 2023: Update billing system to recognize new drugs Rebyota and Zinplava for C. difficile treatment. By May 2, 2023: Review ABA therapy billing procedures - group treatment sessions no longer limited to social skills only, and assessments by behavioral technicians are now excluded services unless in their legal scope. By April 9, 2023: Verify prior authorization requirements have been updated for radiology (CT/MRI), cardiology imaging, and radiation oncology services per new Carelon Medical Benefits Management guidelines. Claims may be denied if new criteria are not met.