Summary
Capital Blue Cross updated its medical policies with an effective date of November 1, 2026 unless otherwise indicated, and many revisions take effect December 1, 2026. Changes include new prior authorization for J9999 and C9399 (Sarclisa Escena) effective November 1, 2026, and for J9041, J9046, J9048, J9049, J9054 and J9999 (bortezomib) and J9292 (Axtle) effective December 1, 2026, along with new step therapy requirements for several drugs. Other revisions remove prior authorization for procedure codes 34701, 34703, 34705, 34707, 96920, 96921, 96922 and 64566, add prior authorization for 17106, 17107 and 17108, and list L2006 as non-covered once it is removed from prior authorization.
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What to do
Action · 18 steps
01Already effective November 1, 2026: Billing team, for commercial Sarclisa Escena, obtain prior authorization before billing J9999 and C9399, because they now require PA for the new drug.
02Check the Capital Blue Cross Single source preauthorization list on the CapBlueCross.com provider web page for codes that require preauthorization.
03For commercial medical specialty injectables delegated to Prime Medical Pharmacy Solutions, submit PA requests online through the Prime MPS GatewayPA Portal at GatewayPA.com.
04If PA cannot be done online, Prime MPS accepts requests by telephone at 800.424.1710 or by fax at 888.656.6671, and urgent or expedited requests should be called in to Prime.
05Commercial endovascular graft procedure codes 34701, 34703, 34705 and 34707 no longer require PA under MP 1.090, which is retired, and InterQual will manage them.
06Also review the new commercial policies Audio Visual Neuromodulation for Neuropathic Pain (MP 6.065) and Permanently Implanted Prostatic Devices for Benign Prostatic Hyperplasia (MP 4.055), the revised commercial Medical Necessity policy (MP 4.003), which removed the Out of Network services section, and the new Medicare Advantage Medical Necessity policy (MA 4.003).
07Review the draft policies in the Provider Library under Preauthorization and policies, Draft policies, Medical policies, for updated criteria and related coding.
08Future changes, effective December 1, 2026: Before billing bortezomib codes J9041, J9046, J9048, J9049, J9054 and J9999 or pemetrexed code J9292 (Axtle) on commercial claims, obtain prior authorization, and follow the new step therapy requirements in the updated bendamustine, bortezomib and pemetrexed policies.
09Review the updated policy for each other revised commercial medical injectable listed in the bulletin, including Adcetris, Darzalex IV, Keytruda IV, Keytruda Qlex, Opdivo IV, Opdivo Qvantig, Padcev, Perjeta, Rybrevant, Synagis, Trodelvy and others.
10For commercial ankle-foot and knee-ankle-foot orthoses under MP 6.062, procedure code L2006 is removed from PA and will be non-covered, so review that policy before billing L2006.
11For commercial air and water ambulance under MP 3.017, non-emergent air and water ambulance transport is considered not medically necessary, so review that policy before billing those services.
12For Medicare Advantage rosacea treatment under MA 2.071, procedure codes 17106, 17107 and 17108 will require PA.
13For Medicare Advantage light therapies under MA 2.046, procedure codes 96920, 96921 and 96922 will no longer require PA, and Ultraviolet Light A phototherapy was added to the medically necessary statement, so review the individual coding tables for each light therapy.
14For Medicare Advantage procedure code 64566 under MA 1.134, PA is no longer required, and procedure code 0590T was added to the MA coding table.
15For bio-engineered skin and soft tissue substitutes under MP 1.158 and MA 1.167, Kerecis Omega3 (commercial codes Q1458 and A2019, Medicare Advantage codes Q4158 and A2019) is now medically necessary for diabetic lower extremity ulcers, and the listed codes are investigational, including A2004, A2008, A2019, A2020, A2021, A2036, A2037, A2038, A2039, A2042, A6460, A6461, C1832, C9353, C9354, C9361, Q4124 and Q4238.
16For amniotic products under MP 1.159 and MA 1.159, 111 amniotic procedure codes were added as investigational, and procedure codes 15271 through 15278, 65778, 65779, 65780, 66779, 66780 and 66999 were added to the coding tables for application of amniotic products, so review the coding tables before billing.
17For irreversible electroporation under MP 1.162 and MA 1.162, procedure code 55877 is investigational and prostate tumors were added to the investigational statement.
18For sleep apnea surgery under MP 1.128 and MA 1.128, procedure code 64999 was added to represent an unlisted procedure of the nervous system, the Inspire device was specifically cited as medically necessary, and the Genio Hypoglossal Nerve Stimulation system was added as investigational.
Codes mentioned
J9999C9399J9041J9046J9048J9049J9054J92923470134703347053470796920969219692264566171061710717108L200664999558771527115272152731527415275152761527715278657786577965780667796678066999A2004A2008A2019A2020A2021A2036A2037A2038A2039A2042A6460A6461C1832C9353C9354C9361Q4124Q4238Q1458Q4158
Original notice
AB2026-10-005 Medical policies
capbluecross.com · Always check the source before changing claims.
Related changes
See all Capital Blue Cross changes →AB2026-05-006 Medical policiesHighEffective Jun 1, 2026 · Medical PolicyAB2026-10-002 Medicare onlyHighEffective Dec 1, 2026 · Provider NewsAB2026-11-005 Medical policiesHighEffective Dec 1, 2026 · Medical PolicyAB2026-09-005 Medical policiesHighEffective Oct 1, 2026 · Medical PolicyBrowse every Capital Blue Cross change in the policy list
Related policy hubs
Capital Blue Cross policiesOncologyHematologyPharmacyWound CarePain ManagementSleep MedicineUrologyDermatologyOrthopedicsCode J9999Code C9399Code J9041Code J9046Code J9048Code J9049Code J9054Code J9292Code 34701Code 34703Code 34705Code 34707Code 96920Code 96921Code 96922Code 64566Code 17106Code 17107Code 17108Code L2006Code 64999Code 55877Code 15271Code 15272Code 15273Code 15274Code 15275Code 15276Code 15277Code 15278Code 65778Code 65779Code 65780Code 66779Code 66780Code 66999Code A2004Code A2008Code A2019Code A2020Code A2021Code A2036Code A2037Code A2038Code A2039Code A2042Code A6460Code A6461Code C1832Code C9353Code C9354Code C9361Code Q4124Code Q4238Code Q1458Code Q4158