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Medical Policy and Coding Updates - July 2019
Effective date
Not stated in the notice
Identified
Jun 18, 2026
Summary
Effective July 1, 2019, HER2 inhibitor codes J9356, Q5112, Q5113 and Q5114 and rituximab biosimilar code Q5115 now require review for medical necessity and prior authorization, and transcatheter mitral valve repair code 0544T now requires review for medical necessity and prior authorization. Corneal collagen cross-linking codes 0402T and J2787 and filgrastim biosimilar code Q5110 no longer require review for medical necessity, and J2787 and Q5110 no longer require prior authorization. Codes 0087U, 0088U, 0089U, 0090U, 0094U, 0101U, 0102U, 0103U and 0104U are now reviewed by AIM Specialty Health.
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What to do
Action · 5 steps
01Already effective July 1, 2019: Check current applicability before billing J9356, Q5112, Q5113, Q5114, Q5115 and 0544T, which this update listed as requiring review for medical necessity and prior authorization.
02Code 0552T was listed as now considered noncovered.
03Codes 0402T, J2787 and Q5110 were listed as no longer requiring review for medical necessity, and J2787 and Q5110 were listed as no longer requiring prior authorization.
04Codes 0087U through 0104U were listed as reviewed by AIM Specialty Health.
05Already effective January 1, 2020: Total knee or total hip replacement for osteoarthritis may be considered medically necessary when criteria are met and the surgery is performed in a Designated Center of Excellence, and the pilot applies only to members whose plan includes the Total Joint Replacement Centers of Excellence Program.
Codes mentioned
J9356Q5112Q5113Q5114Q5115J2787Q5110B9002B9004B9006B9998B9999S9340S9341S9342S9343
Original notice
Medical Policy and Coding Updates - July 2019
premera.com · Always check the source before changing claims.
Related changes
See all Premera Blue Cross changes →Medical Policy and Coding Updates - February 2019MediumEffective Feb 1, 2019 · Medical PolicyMedical Policy and Coding Updates - October 2018MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - January 2019MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - August 2019MediumNo effective date · Medical PolicyBrowse every Premera Blue Cross change in the policy list