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Blue Cross Blue Shield of Rhode IslandCommercial · Prior Auth · Physician · RI · Orthopedics, Oncology, Pathology +5 moreHigh impact

Medical policy updates

Effective date
Mar 1, 2025
Identified
Jun 19, 2026

Summary

Effective March 1, 2025, prior authorization is recommended for commercial products for HCPCS E2298 under the online medical necessity criteria, and HCPCS E2513 moves to the prior authorization policy for durable medical equipment. Effective March 1, 2025, prior authorization is required for Medicare Advantage plans and recommended for commercial products for CPT 27427, 29806, 29914, 29915, 29916 and 93656, and prior authorization is removed for CPT 65730, 67800, 67840 and 67966. Effective March 15, 2025, a post-acute care vendor performs utilization management for Medicare Advantage admission, concurrent and retrospective requests for LTACH, skilled nursing facility and acute inpatient rehabilitation level of care, except for members attributed to a Prospect Primary Care Provider.

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What to do

Action · 9 steps
01Already effective March 1, 2025, check current applicability before acting on these changes.
02Billing team: for HCPCS E2298 on commercial claims, prior authorization is recommended using the medical necessity criteria in the online authorization tool.
03For HCPCS E0651, E0668, E0669 and E0183, prior authorization is no longer required for Medicare Advantage plans and is no longer recommended for commercial products.
04For HCPCS E2513, prior authorization is required for Medicare Advantage plans using the online tool criteria and recommended for commercial products using the medical necessity criteria in the Medical Necessity policy.
05For CPT 27427, 29806, 29914, 29915, 29916 and 93656, prior authorization is required for Medicare Advantage plans and recommended for commercial products, using the online tool criteria.
06For CPT 65730, 67800, 67840 and 67966, prior authorization is removed.
07For CPT 0358U, 0459U and 0445U, prior authorization applies to Medicare Advantage and commercial products under the Evaluation of Biomarkers for Alzheimer's Disease policy criteria.
08For CPT 81595, prior authorization is required for Medicare Advantage plans under the Laboratory Tests Post Transplant and for Heart Failure policy criteria.
09Commercial total knee and hip arthroplasty medical necessity criteria were revised, with no coding changes.

Codes mentioned

E2298E2513E0651E0668E0669E0183274272980629914299152991693656657306780067840679668014580230802808499981313815468159581479811718117281441S3865S38668121881235

Original notice

Medical policy updates
bcbsri.com · Always check the source before changing claims.
View original ↗

Related changes

See all Blue Cross Blue Shield of Rhode Island changes →
Policies related to the BIOMARKER Testing Mandate, effective January 1, 2024HighEffective Jan 1, 2024 · Physician / FacilityAdditional CPT and HCPCS Level II code changesHighEffective Jan 1, 2020 · Physician / FacilityMedical policy updatesHighEffective Sep 1, 2026 · Physician / FacilityJanuary 2019MediumNo effective date · 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 changesOrthopedicsOncologyPathologyGeneticsNeurologyOB-GYNPulmonologyCardiologyCode E2298Code E2513Code E0651Code E0668Code E0669Code E0183Code 27427Code 29806Code 29914Code 29915Code 29916Code 93656Code 65730Code 67800Code 67840Code 67966Code 80145Code 80230Code 80280Code 84999Code 81313Code 81546Code 81595Code 81479Code 81171Code 81172Code 81441Code S3865Code S3866Code 81218Code 81235

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