Summary
BlueCross BlueShield of Rhode Island's November 2026 update changes prior authorization and coverage for many lab, genetic and imaging services, most of them effective January 1, 2027 for Medicare Advantage and commercial plans, including removing prior authorization for many biomarker testing codes and adding prior authorization for CPT 0154U. It also adds a physical and occupational therapy review after the 14th visit per episode for fully funded commercial plans at renewal on or after January 1, 2027, and it recorded a November 1, 2026 change that keeps the online tool criteria for shoulder replacement codes while the new draft policy is on hold.
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What to do
Action · 15 steps
01Already effective November 1, 2026: Orthopedic billing and prior authorization staff: the new shoulder joint replacement draft policy (CPT 23470 and 23472) is on hold, so keep using the criteria in the online authorization tool for Medicare Advantage and commercial requests until BCBSRI issues a further update.
02By January 1, 2027, for Medicare Advantage and commercial members: Billing and prior authorization staff: for CPT 81312 and 81595, stop requesting prior authorization, since the notice removes it and covers the service (81595 only with the specific diagnosis codes listed).
03For CPT 81348, S3841, 0564U and 0578U, the criteria move to the online authorization tool or the policy named in the notice, so update the prior authorization checklist for each code.
04For CPT 81234, 81244, 81271, 81331, 81349 and 81364, Medicare Advantage prior authorization is removed and the notice says the service is not covered, while commercial prior authorization is removed and the service is covered.
05For the Medicare Advantage-only group (81161, 81200, 81203, 81228, 81242, 81252, 81255, 81260, 81303, 81304, 81324, 81325, 81326, 81330, 81361, 81363 and 81448), prior authorization is removed and the notice says the service is not covered, so tell providers and scheduling staff before ordering.
06The notice does not say whether patients may be billed, so check with BCBSRI before billing any member.
07Breast cancer biomarker testing: add CPT 0154U to the prior authorization list for Medicare and commercial members, since the notice says it will require prior authorization under the policy criteria, and note the policy's new title, Genetic Variant Testing (Including Liquid Biopsy) for Targeted Treatment in Advanced Cancer.
08Lipoprotein(a) testing: CPT 83695 is covered once per lifetime for members age 18 and older, so add a frequency check in charge entry so a second test is flagged.
09Implantable device codes: prior authorization is removed for CPT 0661T for Medicare Advantage, and the notice says all codes in the Removal of Implantable Devices policy no longer need prior authorization for Medicare Advantage or commercial plans, so update the prior authorization tracker.
10Prostate biopsy: saturation biopsy (policy for CPT codes in the prostate biopsy policy) becomes covered for Medicare Advantage and commercial members, so update scheduling and prior authorization notes.
11Stem cell therapy (CPT 20999): the notice says it will not be covered for Medicare Advantage and not medically necessary for commercial plans, so do not schedule it without discussing that determination with the provider and check with BCBSRI on any member billing.
12Superficial radiation therapy (Medicare Advantage only): CPT 77436 and 77438 become covered, and 77437 becomes covered when filed with the modifier and covered diagnosis codes in the policy, so update charge entry for Medicare Advantage claims; commercial coverage does not change.
13Prenatal diagnostic testing: review the revised criteria for Medicare Advantage and commercial orders with OB and genetics staff.
14Therapy clinics: from the renewal on or after January 1, 2027, count visits per episode of care for fully funded commercial members, because visits after the 14th will be reviewed for medical necessity by BCBSRI's therapy vendor, and the notice exempts certain mandated code and diagnosis combinations (breast reconstruction and mastectomy) from that review.
15The sensory integration therapy, auditory integration therapy and electrical stimulation wound treatment policies are archived January 1, 2027, so remove them from the policy reference list.
Codes mentioned
234702347283695209997743677438774378131281348812348124481271813318134981364815958116181200812038122881242812528125581260813038130481324813258132681330813618136381448S3841
Original notice
Medical policy updates
bcbsri.com · Always check the source before changing claims.
Related changes
See all Blue Cross Blue Shield of Rhode Island changes →January 2018MediumEffective Jan 1, 2018 · Provider UpdateJanuary 2019MediumNo effective date · Provider UpdateMedical policy updatesHighEffective Nov 1, 2026 · Physician / FacilityFebruary 2018MediumEffective Jan 1, 2018 · Provider UpdateBrowse every Blue Cross Blue Shield of Rhode Island change in the policy list
Related policy hubs
Blue Cross Blue Shield of Rhode Island policiesRI policy changesPathologyOncologyGeneticsNeurologyOrthopedicsOB-GYNUrologyRadiation OncologyPM&R (Physical Medicine & Rehab)Physical TherapyOccupational TherapyCode 23470Code 23472Code 83695Code 20999Code 77436Code 77438Code 77437Code 81312Code 81348Code 81234Code 81244Code 81271Code 81331Code 81349Code 81364Code 81595Code 81161Code 81200Code 81203Code 81228Code 81242Code 81252Code 81255Code 81260Code 81303Code 81304Code 81324Code 81325Code 81326Code 81330Code 81361Code 81363Code 81448Code S3841