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

Medical Policy and Coding Updates - December 2022

Effective date
Apr 9, 2023
Identified
Jun 18, 2026

Summary

Botulinum toxin codes J0585, J0586, J0587 and J0588 require review for medical necessity and prior authorization for dates of service starting on and after December 1, 2022, under the temporomandibular joint disorder and hyperhidrosis policies. Coding changes effective December 1, 2022 also set C9142 to require medical necessity review, changed J0172 to require investigational review with prior authorization still required, and removed medical necessity review for A9593, A9594, A9595, A9596 and A9800. Drug policy updates added Botox, Dupixent for prurigo nodularis, Sotyktu for plaque psoriasis, and Vegzelma and Alymsys in the VEGF inhibitor policy.

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What to do

Action · 7 steps
01Already effective December 1, 2022: For dates of service starting on and after December 1, 2022, botulinum toxin codes J0585, J0586, J0587 and J0588 require review for medical necessity and prior authorization under the temporomandibular joint disorder and hyperhidrosis policies.
02Billing team: confirm prior authorization is in place for these codes before billing them.
03Already effective December 1, 2022: C9142 requires review for medical necessity under the VEGF inhibitor policy.
04J0172 no longer requires review for medical necessity, now requires review for investigational status, and still requires prior authorization.
05A9593, A9594, A9595, A9596 and A9800 no longer require medical necessity review, now require investigational review, and still require prior authorization.
06Already effective January 6, 2023: 90870 requires review for medical necessity and prior authorization under the InterQual criteria policy, and 27703 no longer requires review.
07Check current applicability of these dates before acting on them.

Codes mentioned

J0585J0586J0587J0588C9142J0172A9593A9594A9595A9596A98009087027703

Original notice

Medical Policy and Coding Updates - December 2022
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 - October 2022MediumEffective Dec 1, 2022 · Medical PolicyMedical Policy and Coding Updates - November 2022MediumEffective Feb 18, 2023 · Medical PolicyMedical Policy and Coding Updates - August 2022MediumEffective Nov 4, 2022 · Medical PolicyMedical Policy and Coding Updates - September 2022MediumEffective Dec 1, 2022 · Medical PolicyBrowse every Premera Blue Cross change in the policy list

Related policy hubs

Premera Blue Cross policiesWA policy changesAK policy changesOncologyHematologyOphthalmologyNeurologyUrologyGastroenterologyDermatologyRheumatologyOrthopedicsPharmacyPsychiatryOB-GYNPlastic SurgeryCode J0585Code J0586Code J0587Code J0588Code C9142Code J0172Code A9593Code A9594Code A9595Code A9596Code A9800Code 90870Code 27703

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