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MA12.010e, Remote Physiologic Monitoring and Remote Therapeutic Monitoring
Effective date
Nov 30, 2026
Identified
Oct 31, 2026
Summary
Effective 11/30/2026, Independence Blue Cross Medicare Advantage is updating medical policy MA12.010e to change remote patient monitoring (RPM and RTM) coverage from a blanket covered status to medically necessary with specific criteria. Coverage is now limited to patients with heart failure, hypertension, or diabetes mellitus, with 16 CPT/HCPCS codes now eligible only when specific diagnoses and clinical criteria are met. Billing teams must update authorization logic, documentation requirements, and claim submission workflows to reflect the new diagnosis-based eligibility rules.
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What to do
Action · 5 steps
01By 11/30/2026, the billing team must.
02Update the billing system and prior authorization workflows to require one of the specified diagnoses (heart failure, hypertension, or diabetes mellitus) for CPT codes 98975, 98976, 98977, 98979, 98980, 98981, 98984, 98985, 99091, 99445, 99453, 99454, 99457, 99458, 99470, and HCPCS code S9110 to be eligible for reimbursement under Independence Blue Cross Medicare Advantage plans.
03Ensure that providers document patient consent, FDA-approved device usage, and monitoring frequency (at least 16 days per 30-day period for RPM, at least 2 days per 30-day period for RTM) in the medical record before claim submission.
04Implement validation rules to deny or require correction for claims exceeding two monitoring periods (60 days) without documented risk calculator evidence (e.g., 30-day Readmission Yale Core Risk Calculator) justifying extended monitoring.
05Add rules to prevent bundling of RPM with RTM codes and to exclude monitoring during postoperative periods from separate reimbursement.
If missed: Failure to implement these changes will result in claim denials for non-compliant submissions.
Codes mentioned
989759897698977989799898098981989849898599091994459945399454994579945899470S9110
Original notice
MA12.010e, Remote Physiologic Monitoring and Remote Therapeutic Monitoring
medpolicy.ibx.com · Always check the source before changing claims.
Related changes
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