Medicare AdvantagePrior AuthHigh impact
Medical policy updates
Blue Cross Blue Shield of Rhode Island·Cardiology, Oncology, OB-GYN +2 more·Physician / Facility
Effective date
Nov 1, 2024
We identified it
Jun 19, 2026
Summary
Multiple significant coverage and prior authorization changes take effect November 1, 2024, including removal of prior auth requirements for genetic testing codes 81518-81523 and 81225-81226 (when filed with specific diagnosis codes), changes to powered exoskeleton coverage (E0739), and new prior auth requirements for pelvic congestion syndrome treatment and prostate cancer detection. These changes affect both Medicare Advantage and commercial plans with different coverage determinations for each plan type.
Action Required
By November 1, 2024: Billing team must update prior authorization requirements in billing system - remove prior auth for CPT codes 81518-81523 and 81225-81226 when filed with covered ICD-10 codes, add prior auth requirement for CPT 37241 with N94.89, add prior auth for CPT 0359U (Medicare Advantage), and update coverage status for E0739 (not covered for Medicare Advantage, not medically necessary for commercial). Update encounter forms and staff training on new genetic testing coverage criteria. Claims without proper ICD-10 code matching will be denied.