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Premera Blue CrossAll Plans · Prior Auth · Medical Policy · WA, AK · Orthopedics, Sports Medicine, Oncology +14 moreMedium impact

Medical Policy and Coding Updates - April 2020

Effective date
Not stated in the notice
Identified
Jun 18, 2026

Summary

This WA and Alaska medical policy and coding update lists changes with effective dates from April 1, 2020 through July 2, 2020. For dates of service July 2, 2020 and after, the plan will use InterQual criteria to review medical necessity for listed services, including Knee Arthroplasty in Adults, Hip Arthroplasty in Adults and Knee Arthroscopy in Adults, and the plan will begin reviewing C series HCPC codes. Coding updates list genetic testing codes 0169U, 0170U and 0171U as requiring review for medical necessity and prior authorization effective April 1, 2020, and list drug codes C9053, C9056 and C9058 as requiring review for medical necessity and prior authorization effective July 2, 2020.

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What to do

Action · 7 steps
01Already effective April 1, 2020: Get prior authorization for 0169U, 0170U and 0171U, which the source says now require review for medical necessity and prior authorization.
02Colorectal cancer screening codes 0002U and 0163U now require review for investigative status.
03Genetic testing code 81507, hematopoietic cell transplantation code 38242 and transcatheter aortic valve codes 33367, 33368 and 33369 no longer require review for medical necessity and prior authorization.
04Already effective July 2, 2020: Get prior authorization for C9053, C9056 and C9058, which now require review for medical necessity and prior authorization.
05Sign in to the provider website to view InterQual criteria, since the plan uses InterQual criteria to review medical necessity for the listed services, including Knee Arthroplasty in Adults (7.01.550), Hip Arthroplasty in Adults (7.01.573) and Knee Arthroscopy in Adults (7.01.549).
06Site of service is now included in the medical necessity review for the primary knee procedure under InterQual criteria for autologous chondrocyte implantation and meniscal allograft procedures.
07Check current applicability before acting on these dates, and read the full policy at the source link for the other dates in this update.

Codes mentioned

C9053C9056C90588150738242333673336833369

Original notice

Medical Policy and Coding Updates - April 2020
premera.com · Always check the source before changing claims.
View original ↗

Related changes

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Related policy hubs

Premera Blue Cross policiesWA policy changesAK policy changesOrthopedicsSports MedicineOncologyHematologyGeneticsGastroenterologyCardiologyNeurologyPediatricsWound CareOphthalmologyDermatologyUrologyTransplant SurgeryPharmacyEndocrinologyRheumatologyCode C9053Code C9056Code C9058Code 81507Code 38242Code 33367Code 33368Code 33369

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