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Medical Policy and Coding Updates - November 2019
Premera Blue Cross·WA · Radiology, Diagnostic Imaging, Oncology +7 more·Medical Policy
Effective date
Feb 9, 2020
We identified it
Jun 18, 2026
Summary
This policy update includes multiple changes to AIM Specialty Health clinical appropriateness guidelines for advanced imaging, radiation therapy, and sleep disorder management, plus updates to various medical policies for specific drugs and procedures. The changes primarily affect prior authorization requirements and coverage criteria for imaging studies, specialty medications, and certain surgical procedures.
Action Required
By February 9, 2020: Clinical and billing teams must update prior authorization processes for AIM Specialty Health guidelines including new requirements for ultrasound-first approach for pediatric abdominal/pelvic pain, DVT exclusion before abdominopelvic imaging for lower extremity edema, and updated criteria for various imaging studies. Update encounter forms and EMR templates to reflect new documentation requirements for splenic masses, pancreatic masses, inflammatory bowel disease, and sleep disorder studies. Review drug formulary updates for rare disease medications and oncology drugs to ensure proper billing and prior authorization workflows.