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Premera Blue CrossAll Plans · Prior Auth · Medical Policy · WA · Genetics, Pharmacy, Oncology +12 moreMedium impact

Medical Policy and Coding Updates - October 2018

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

Summary

Effective October 1, 2018, CYP450 drug metabolizer genotyping codes 0028U, 0029U, 0031U, and 0070U through 0076U now require medical necessity review and prior authorization. Effective October 1, 2018, pegfilgrastim biosimilar Fulphila (Q5108) and filgrastim biosimilar Nivestym (Q5110) have medical necessity criteria added under the G-CSF policy, and custom ankle-foot and knee-ankle-foot orthoses (L1945, L2755) now require medical necessity review and prior authorization. MRgFUS ablation for movement disorder (0398T) now requires medical necessity review and prior authorization. Home enteral nutrition in-line digestive enzyme cartridges (Q9994), pain management opioid-use disorder genotyping (0078U), and sphenopalatine ganglion block (64505) are now reviewed as investigational. Drug testing with definitive confirmation (0020U) and knee orthosis L1847 no longer require medical necessity review, and L1847 no longer requires prior authorization, while supply code T5999 is now a non-covered service.

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What to do

Action · 13 steps
01These effective dates passed in 2018 and later, so confirm current applicability with Premera before billing these services.
02Prior authorization: obtain prior authorization before billing 0028U, 0029U, 0031U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U and 0076U, which the notice says now require medical necessity review and prior authorization.
03Obtain prior authorization before billing Q5108, Q5110, L1945, L2755 and 0398T.
04Investigational: Q9994, 0078U and 64505 are now reviewed as investigational.
05Medical necessity: 0020U no longer requires medical necessity review.
06L1847 no longer requires medical necessity review or prior authorization.
07Non-covered: T5999 is now a non-covered service under policy 10.01.517.
08Other policy changes listed in the notice, with dates, for review on the Premera medical policies page: Pulsed radiofrequency and ablative treatments for occipital neuralgia, chronic headaches and atypical facial pain are investigational as of December 6, 2018.
09Peripheral neuroma ablation and alcohol injections for peripheral neuromas are investigational as of November 2, 2018.
10Cardiac hemodynamic monitoring for the management of heart failure in the outpatient setting (2.02.24) was reinstated and is considered investigational.
11Lymphatic physiologic microsurgery for lymphedema is investigational as of January 4, 2019.
12Knee, ankle-foot and knee-ankle-foot orthoses policy 1.03.501 changed as of October 1, 2018.
13Opioid therapy was revised under policy 5.01.529, and policies 5.01.579 and 5.01.583 were deleted as of October 1, 2018.

Codes mentioned

Q5108Q5110L1945L2755Q999464505L1847T5999

Original notice

Medical Policy and Coding Updates - October 2018
premera.com · Always check the source before changing claims.
View original ↗

Related changes

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Medical Policy and Coding Updates - January 2019MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - July 2019MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - November 2026HighEffective Nov 1, 2026 · Medical PolicyMedical Policy and Coding Updates - November 2026HighNo effective date · Medical PolicyBrowse every Premera Blue Cross change in the policy list

Related policy hubs

Premera Blue Cross policiesWA policy changesGeneticsPharmacyOncologyHematologyGastroenterologyNeurologyPain ManagementDermatologyRheumatologyCardiologyRadiologyNephrologyOB-GYNOrthopedicsGeneral SurgeryCode Q5108Code Q5110Code L1945Code L2755Code Q9994Code 64505Code L1847Code T5999

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