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Blue Cross Blue Shield of Rhode IslandMedicare Advantage · Prior Auth · Physician / Facility · Cardiology, Oncology, OB-GYN +2 moreHigh impact

Medical policy updates

Act
by Nov 1, 2024
Effective date
Nov 1, 2024
Identified
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.

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What to do

by Nov 1, 2024 · 3 steps
01Billing 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).
02Update encounter forms and staff training on new genetic testing coverage criteria.
03Claims without proper ICD-10 code matching will be denied.

Codes mentioned

L5841E073981518815198152081521815228152337241N94.898122581226F01F99826108369583722838808538485385E2298

Original notice

Medical policy updates
bcbsri.com · Always check the source before changing claims.
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Related changes

See all Blue Cross Blue Shield of Rhode Island changes →
Medical policy updatesHighEffective Feb 1, 2026 · Physician / FacilityPolicy updatesHighEffective Apr 1, 2024 · Physician / FacilityAdditional HCPCS Level II Code Changes and Modifier ChangesHighEffective Apr 1, 2024 · Physician / FacilityMedical policy updatesHighEffective Feb 1, 2026 · Physician / FacilityBrowse every Blue Cross Blue Shield of Rhode Island change in the policy list

Related policy hubs

Blue Cross Blue Shield of Rhode Island policiesCardiologyOncologyOB-GYNUrologyOrthopedicsCode L5841Code E0739Code 81518Code 81519Code 81520Code 81521Code 81522Code 81523Code 37241Code N94.89Code 81225Code 81226Code F01Code F99Code 82610Code 83695Code 83722Code 83880Code 85384Code 85385Code E2298

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