Keeping up with insurance policy changes that affect Orthopedics practices is a full-time job. This page aggregates the latest payer updates (prior authorization rule changes, reimbursement adjustments, billing code additions and removals, and coverage policy revisions) across all major insurers. Changes are identified and summarized daily so Orthopedics providers and their billing teams can act before deadlines pass.
Arkansas Blue Cross is removing a previous non-coverage statement for steroid injections into facet joints, effectively reversing a blanket denial and making these procedures potentially coverable under Primary Coverage Criteria. Billing teams must immediately stop denying facet joint steroid injection claims based on the old non-coverage policy and begin processing them according to individual member benefit certificates and medical necessity determinations.
Effective for dates of service on and after Nov. 15, 2026, Carelon's clinical appropriateness guidelines change for Medicaid members in New York. Genetic testing guidelines add a requirement that all components of a test must demonstrate clinical utility, and whole exome, whole genome and whole transcriptome analysis are considered not medically necessary. For joint surgery, the required conservative management duration is standardized to 12 weeks across procedures, and new criteria cover electrical and ultrasound bone growth stimulation devices for conditions of the appendicular skeleton.
Effective for dates of service on and after Nov. 15, 2026, Carelon's clinical appropriateness guidelines change for Anthem Blue Cross and Blue Shield Medicaid and MyCare Ohio plans in Ohio. Genetic testing guidelines add a requirement that all components of a test must demonstrate clinical utility, and whole exome, whole genome and whole transcriptome analysis are considered not medically necessary. For joint surgery, the required conservative management duration is standardized to 12 weeks across procedures, and new criteria cover electrical and ultrasound bone growth stimulation devices for conditions of the appendicular skeleton.
Effective for dates of service on and after November 15, 2026, the Carelon Medical Benefits Management Clinical Appropriateness Guidelines are updated for Anthem Blue Cross and Blue Shield commercial plans in Ohio. The updates cover vascular embolization, varicose vein treatment, PFO closure, genetic and liquid biopsy testing, joint surgery, hypoglossal nerve stimulators and upper GI endoscopy. For upper endoscopy, EGD for new-onset dyspepsia is medically necessary in patients 55 or older rather than 50 or older, and EGD for weight loss requires a loss of 5% or more of usual body weight over the past 12 months. For joint surgery, conservative management is standardized to 12 weeks across procedures, with a shorter allowance for severe ADL impacts, and shoulder, hip and knee arthroscopy adds an exclusion for Kellgren-Lawrence grade 4 osteoarthritis.
Effective for dates of service on and after November 15, 2026, updated Carelon Medical Benefits Management Clinical Appropriateness Guidelines apply to Medicare Advantage. Genetic and somatic tumor testing requires that all components of a test demonstrate clinical utility, and whole exome, whole genome and whole transcriptome analysis are considered not medically necessary. Joint procedures now require 12 weeks of conservative management with a shorter allowance for severe impact on daily activities, arthroscopy is excluded for Kellgren-Lawrence grade 4 osteoarthritis, and bilateral hypoglossal nerve stimulators are excluded for obstructive sleep apnea.
Effective for dates of service on and after November 15, 2026, updated Carelon Medical Benefits Management Clinical Appropriateness Guidelines apply to Medicare Advantage. Genetic and somatic tumor testing requires that all components of a test demonstrate clinical utility, and whole exome, whole genome and whole transcriptome analysis are considered not medically necessary. Joint procedures now require 12 weeks of conservative management with a shorter allowance for severe impact on daily activities, arthroscopy is excluded for Kellgren-Lawrence grade 4 osteoarthritis, and bilateral hypoglossal nerve stimulators are excluded for obstructive sleep apnea.
Carelon Medical Benefits Management updated its clinical appropriateness guidelines for Anthem Medicare Advantage plans in Virginia, effective for dates of service on and after November 15, 2026. Genetic testing changes require that all components of a test demonstrate clinical utility, add imlunestrant to the therapies for which ESR1 mutation testing is considered medically necessary, and state that testing for breast cancer recurrence is not medically necessary. Orthopedic changes standardize conservative management to 12 weeks across procedures, with an allowance for shorter duration for severe ADL impacts, and exclude Kellgren-Lawrence grade 4 osteoarthritis from shoulder, hip and knee arthroscopy.
Carelon Medical Benefits Management updated its clinical appropriateness guidelines for Anthem Blue Cross and Blue Shield Medicare Advantage plans in Georgia, effective for dates of service on and after November 15, 2026. Genetic testing changes require that all components of a test demonstrate clinical utility, add imlunestrant to the therapies for which ESR1 mutation testing is considered medically necessary, and state that testing for breast cancer recurrence is not medically necessary. Orthopedic changes standardize conservative management to 12 weeks across procedures, with an allowance for shorter duration for severe ADL impacts, and exclude Kellgren-Lawrence grade 4 osteoarthritis from shoulder, hip and knee arthroscopy.
Effective November 30, 2026 at 12:00 AM, Ambetter Health and Superior HealthPlan updated several clinical policies for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP and Ambetter Health products. A new policy sets medical necessity criteria for skin and soft tissue substitutes for diabetic foot ulcers, venous leg ulcers and burns, covering up to four initial applications and continued treatment up to ten applications per wound per 12-week episode. Selective nerve root block criteria now apply to diagnostic purposes only, and all therapeutic indications were removed.
UnitedHealthcare Community Plan of Idaho revised its Medicaid medical policy on treatment of temporomandibular joint (TMJ) disorders, effective 2026-12-01. TMJ arthroplasty is now the only TMJ surgical service described as proven and medically necessary in certain circumstances, with medical necessity criteria pointing to InterQual CP: Procedures, Arthroplasty, Temporomandibular Joint (TMJ) (Custom) - UHG; arthroscopy and discectomy criteria were removed. CPT codes 21060, 21247, 29800, and 29804 were removed from the applicable codes list.
Effective 2026-12-01, UnitedHealthcare Community Plan of Idaho revised its Surgery of the Shoulder medical policy for Idaho Medicaid members: medical necessity criteria now point to InterQual CP procedure criteria for shoulder arthroscopy, arthrotomy and joint replacement, and CPT 29805 was removed from the applicable codes. The policy also states that subacromial balloon spacers for rotator cuff tears are unproven and not medically necessary.
Capital Blue Cross administrative bulletin 2026-11-005, dated November 1, 2026, lists medical policy updates with an effective date of December 1, 2026 unless otherwise indicated. Changes effective December 1, 2026 include added procedure codes in the Durable Medical Equipment policy and new preauthorization requirements for several Prime Therapeutics injectables. Many other changes take effect January 1, 2027, including EviCore's Clinical Guidelines for Lab Management Program, Version 1.0.2027, updated Evolent radiology and radiation oncology guidelines, and updated TurningPoint musculoskeletal and cardiology policies.
UnitedHealthcare Community Plan of Nebraska revised its hip surgery medical policy effective December 1, 2026. The policy removed the diagnostic arthroscopy InterQual criterion, deleted CPT code 29860, and added explicit exclusion criteria: surgical treatment for Femoroacetabular Impingement Syndrome is not medically necessary when advanced osteoarthritis (Tönnis grade 2-3) or severe cartilage damage (Outerbridge Grade III-IV) is present. Billing teams must immediately identify claims for CPT 29860 and update authorization protocols for hip procedures.
Effective December 1, 2026, CareSource is expanding TurningPoint's Cardiac and Musculoskeletal Surgical Quality and Safety Management Program to Indiana Medicaid members (Healthy Indiana Plan and Hoosier Healthwise). Prior authorization is now REQUIRED for all cardiac surgeries and musculoskeletal/orthopedic procedures listed in the policy before service delivery. Claims without prior authorization will be denied.
Sentara Health Plans has updated 27 medical and surgical policies effective December 1, 2026, including revisions to high-volume procedures like lumbar/cervical fusion, diabetes management, urinary incontinence treatment, and prescription digital therapeutics. Three DME policies (Needless Injections, Mechanical Stretching Devices, Home Traction Devices) have been archived and are no longer covered. Billing teams must review affected policies on the PAL and update prior authorization requirements accordingly.
UnitedHealthcare Commercial has established new medical policy guidelines for vascular embolization procedures effective December 1, 2026. The policy covers renal embolization for specific oncological and non-oncological indications and references InterQual criteria for liver malignancy treatment, while explicitly denying coverage for hemorrhoid and musculoskeletal pain indications (genicular artery, shoulder, adhesive capsulitis, tendinitis, plantar fasciitis). Billing teams must implement coverage denials for non-covered indications and ensure prior authorization aligns with InterQual and NCCN guidelines for covered procedures.
Ambetter Health is implementing two program enhancements effective December 2026: (1) Beginning December 1, Evolent will issue direct denial determinations for oncology prior authorizations that don't meet clinical criteria instead of issuing Recommended Adverse Determinations; (2) Beginning December 5, Evolent will require site-of-care selection for shoulder, hip, knee, and spine surgeries with clinical justification if hospital-based settings are chosen for outpatient-eligible procedures.
Effective December 1, 2026, Anthem Blue Cross Medicare Advantage plans in California are adding prior authorization requirements for 30 specific procedure and supply codes, including prostate cancer screening (0591U), skin graft procedures (1044T-1049T, G0682, G0684), esophageal procedures (43192, 43201, 43210, 43236, 43497), neurolytic injections (64624), wound care matrices, neurostimulator generators, and orthotic devices. Claims submitted without prior authorization for these codes may be denied as ineligible for payment.
Effective December 1, 2026, Anthem Blue Cross Medicare Advantage (ISNP and CSNP plans) in California is adding 32 new codes to their prior authorization requirement list, spanning oncology testing, advanced skin grafting procedures, esophageal/gastric interventions, pain management, wound care products, and orthotic devices. All claims for these services submitted without prior authorization will be deemed ineligible for payment.
Effective December 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage (ISNP and CSNP plans) in Virginia will require prior authorization for 30 new procedure and supply codes, including prostate cancer screening, skin grafting procedures, esophageal procedures, neurolytic injections, wound care products, and durable medical equipment. Claims submitted without prior authorization for these codes will be denied as ineligible for payment.
Effective December 5, 2026, Ambetter from WellCare of Kentucky (through Evolent) is implementing site-of-care requirements for shoulder, hip, knee, and spine surgeries. Ordering providers must now select a preferred outpatient site when submitting authorization requests for procedures that can be performed in an outpatient setting; hospital-based site selection will require either an allowable exception or clinical justification. Prior authorizations will reflect determinations for both the procedure and site of care.
Ambetter of North Carolina's October 2026 provider newsletter, dated 10/22/26, announces that beginning 12/05/26 Evolent will guide ordering providers to select a preferred site of care when they request authorization for shoulder, hip, knee and spine surgeries. The newsletter also says claims from Critical Access Hospitals with an incorrect Type of Bill will be denied and require correction and resubmission, that claims with surrogacy diagnosis codes Z33.3 or Z31.7 trigger an automatic one-year member review, and that Ambetter payments are moving to Zelis, with Medicare, Medicaid, and Ambetter programs moving in early 2027.
Effective December 5, 2026, Evolent will implement site-of-care selection requirements for shoulder, hip, knee, and spine surgeries for Ambetter from WellCare of New Jersey members. Ordering providers must now specify preferred outpatient or inpatient settings during authorization requests; hospital-based settings for outpatient-eligible procedures require either selection from allowable exceptions or clinical justification. Clinical reviewers will evaluate both medical necessity and site of care before authorization is finalized.
Effective December 5, 2026, Evolent is implementing new site-of-care selection requirements for shoulder, hip, knee, and spine surgeries across its Medicaid, Marketplace, and Medicare plans. Ordering providers must now select a preferred outpatient or inpatient site during prior authorization intake; if hospital-based settings are chosen for procedures safely performed in outpatient settings, providers must document clinical justification or select from allowable exceptions. Clinical reviewers will evaluate both medical necessity and site of care before rendering authorization determinations.
Effective December 5, 2026, Evolent (on behalf of Sunflower) is implementing new site-of-care selection requirements for shoulder, hip, knee, and spine surgeries. Ordering providers must now select a preferred outpatient or inpatient site during authorization requests; if hospital-based settings are chosen for procedures that can be performed outpatient, providers must justify the selection or select from allowable exceptions. Clinical reviewers will evaluate both medical necessity and site-of-care criteria before authorization.
Beginning December 5, 2026, Superior HealthPlan and Ambetter Health will require prior authorization requests for musculoskeletal surgeries (shoulder, hip, knee, spine) to specify a preferred site of care. Providers selecting hospital-based settings for procedures that can be performed in outpatient settings must either choose from allowable exceptions or provide clinical justification. Clinical reviewers will evaluate both medical necessity and site-of-care criteria before rendering authorization determinations.
Effective December 5, 2026, Evolent will implement new site-of-care selection requirements for shoulder, hip, knee, and spine surgeries for Ambetter Marketplace members. Providers must select outpatient settings when clinically appropriate; if hospital-based settings are chosen for procedures that can be performed outpatient, providers must document allowable exceptions or provide clinical justification. Clinical reviewers will evaluate both medical necessity and site of care before authorization.
Effective December 5, 2026, Evolent/Ambetter from Meridian is implementing a new site-of-care selection requirement for shoulder, hip, knee, and spine surgeries. Providers must now select a preferred outpatient or inpatient site during prior authorization requests; if hospital-based care is chosen for procedures eligible for outpatient settings, providers must justify with clinical documentation or select from allowable exceptions. Final authorizations will reflect determinations for both the procedure and site of care.
Effective December 5, 2026, Evolent is implementing mandatory site-of-care selection for shoulder, hip, knee, and spine surgeries for Home State Health, Show Me Healthy Kids, and Ambetter from Home State Health members. Providers must justify hospital-based settings for procedures that can be safely performed in outpatient settings, or select from allowable exceptions. Clinical reviewers will evaluate both medical necessity and site of care before issuing final authorization.
Effective December 15, 2026, Evolent (for Ambetter from Meridian members) is implementing mandatory site-of-care selection for shoulder, hip, knee, and spine surgeries. Providers must now choose outpatient settings for procedures that can be safely performed outside hospitals, or provide clinical justification for inpatient admission. Both procedure medical necessity and site of care will be evaluated during authorization review.
Blue Cross and Blue Shield of Oklahoma is removing prior authorization requirements for specific service categories (proprietary laboratory analyses, drugs/biologics, molecular pathology/genetics, infectious disease molecular testing, radiology, advanced imaging, orthopedic surgery, foot and ankle surgery, plastic/reconstructive surgery, vascular surgery, organ transplant, general surgery, ophthalmology, and miscellaneous specialty procedures) for Medicare Advantage members effective December 21, 2026. Additionally, the plan will begin phasing out Recommended Clinical Review options starting January 1, 2027, with complete removal expected by end of 2027 for most commercial members.
Blue Cross and Blue Shield of Texas is removing prior authorization requirements for specific service categories (laboratory analyses, drugs/biologics, molecular pathology, infectious disease testing, radiology, advanced imaging, orthopedic surgery, foot and ankle surgery, plastic/reconstructive surgery, vascular surgery, organ transplant, general surgery, ophthalmology, and miscellaneous specialty procedures) for Medicare Advantage members effective December 21, 2026. Additionally, the plan will begin reducing and eventually eliminating the 'Recommended Clinical Review' option from utilization management processes for most commercial members by end of 2027, with ERS and TRS excluded from this change.
Blue Cross and Blue Shield of Montana is removing prior authorization requirements for specific procedure categories (proprietary laboratory analyses, drugs and biologics, molecular pathology/genetics, infectious disease molecular testing, radiology and advanced imaging, orthopedic surgery, foot and ankle surgery, plastic/reconstructive surgery, vascular surgery, organ transplant, general surgery, ophthalmology, and miscellaneous specialty procedures) for Medicare Advantage members effective December 21, 2026. Additionally, the organization will begin phasing out Recommended Clinical Review options starting January 1, 2027, with complete removal expected by end of 2027 for most commercial members.
Blue Cross Blue Shield of New Mexico is removing prior authorization requirements for specific service categories (proprietary laboratory analyses, drugs/biologics, molecular pathology, infectious disease testing, radiology, advanced imaging, orthopedic surgery, foot and ankle surgery, plastic/reconstructive surgery, vascular surgery, organ transplant, general surgery, and ophthalmology) for Medicare Advantage members effective December 21, 2026. Additionally, the plan will begin phasing out the 'Recommended Clinical Review' option starting January 1, 2027, with full removal expected by end of 2027 for most commercial members.
Effective 2027-01-01, UnitedHealthcare Community Plan of New Mexico Medicaid expanded its denosumab policy: Jubereq and Osvyrti are preferred products covered under the Diagnosis-Specific Criteria, while Boncresa, Oziltus, and Ponlimsi are non-preferred and covered only when the Preferred Product Criteria and Diagnosis-Specific Criteria are both met. The postmenopausal osteoporosis criteria add a very-high-fracture-risk pathway for initial therapy, and HCPCS codes Q5166, Q5171, and Q5173 were added.
UnitedHealthcare Community Plan of Kentucky's Medicaid medical policy for denosumab was revised effective 2027-01-01, updating the list of covered denosumab products by adding Boncresa, Jubereq, Osvyrti, Oziltus, and Ponlimsi, with Jubereq and Osvyrti designated preferred and Boncresa, Oziltus, and Ponlimsi designated non-preferred. Coverage for postmenopausal osteoporosis treatment was revised to add an initial-therapy criterion for very high fracture risk (a fracture in the past 12 months or a fracture while on approved osteoporosis therapy), and HCPCS codes Q5166, Q5171, and Q5173 were added. Billing staff should update product and code references and review the new very-high-risk documentation requirements before submitting denosumab claims for these members.
HealthPartners' November 2026 Fast Facts newsletter lists several changes, most effective January 1, 2027: Cigna-insured members will require precertification for outpatient non-emergency CT, MRI and PET imaging; manual and power mobility device codes will require prior authorization for Medicare Advantage, Medicare Cost and MSHO members; Actemra is being replaced by the biosimilar Avtozma and several diabetes and insulin drugs are leaving the formulary; and Minnesota Medicaid moves to MNAAC pharmacy reimbursement. The billing team should also note the standing reminder to submit any change to a previously filed claim as a corrected claim with Bill Frequency Code 7.
Point32Health is updating Medical Necessity Guidelines across several plan lines. Effective 11/1/2026 (already in effect as of the 2026-11-05 analysis date), prior authorization is removed for Carelon-reviewed noninvasive prenatal testing codes 81420 and 81507 on certain commercial lines, and the 6-month trial and renewal criteria are removed for tonic motor activation. Effective 1/1/2027 (future), prior authorization is added for multiple codes on Tufts Medicare Preferred, Tufts Health Plan SCO, and Tufts Health One Care, and coverage criteria are added for SCODI, vitamin B12 and D testing, and benign skin lesion removal.
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.
Aetna's November 2026 OfficeLink newsletter, issued 2026-11-01, covers several changes with different dates. The biggest is a restructuring of maternity care coding, with global maternity codes retired and replaced by service-based codes effective January 1, 2027, plus a transition period for prenatal preventive visits that began September 1, 2026. It also adds precertification for several specialty drugs on staggered dates from November 1, 2026 through February 1, 2027, and notes a Medicare MolDX molecular testing Z-code requirement that has no stated date and an observation reminder that is already in effect.
Effective January 1, 2027, Blue Cross and Blue Shield of Texas will assume prior authorization processing for spinal fusion surgery for TRS participants, replacing Carelon. Prior authorization approval now requires documentation that the participant completed a minimum of six consecutive weeks of physical therapy prescribed by a physician within 12 months of the procedure, and the physical therapy must occur in an office setting or approved online treatment.
Blue Cross Blue Shield of North Dakota is updating medical policies for two procedures effective January 1, 2027: Cervical Spinal Fusion (Surgery #244) with 23 newly added CPT codes, and Fetal Red Blood Cell Antigen Genotyping (Genetic Testing #74) with one added HCPCS code. Billing teams must update their coding systems and verify prior authorization requirements for migrated commercial members on the updated Prior Authorization List.
Anthem Blue Cross and Blue Shield is updating prior authorization (PA) requirements for Ohio-based commercial accounts, effective January 1, 2027. The policy establishes comprehensive PA requirements across inpatient admissions, advanced diagnostic testing, DME/prosthetics, transplants, gene therapies, CAR T-cell treatments, mental health services, and numerous surgical procedures. Billing teams must implement these PA requirements in their workflows and systems before the effective date.
Anthem Blue Cross and Blue Shield's October 2026 notice lists the services that will require prior authorization for national accounts commercial members starting January 1, 2027. The list is broad, covering inpatient admissions (including OB stays beyond the federal minimum length of stay), genetic and diagnostic tests, durable medical equipment, transplant and cell and gene therapies, behavioral health programs, cosmetic and reconstructive surgery, and implanted devices, so scheduling and billing need updates before that date.
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
This policy updates BCBS Wyoming's preferred product program for 2027, adding new biosimilar medications and removing others from preferred status across multiple drug classes (Bevacizumab, Rituximab, Infliximab, Viscosupplements, Ustekinumab, and new categories). Billing teams must identify affected members, update prior authorization workflows, and begin transitioning prescriptions to preferred products effective January 1, 2027, with enforcement at new authorizations and renewals.
Effective January 1, 2027, Anthem is implementing comprehensive prior authorization requirements for National accounts in New York across inpatient admissions, advanced diagnostic testing, specialized DME/prosthetics, transplants, gene therapy, mental health services, and numerous surgical/outpatient procedures. Billing teams must update systems to require pre-certification for these services before claim submission to avoid denials.
Anthem Blue Cross and Blue Shield Ohio is implementing updated prior authorization requirements for national accounts effective January 1, 2027. This comprehensive policy change expands PA requirements across inpatient admissions, advanced diagnostic testing, specialized DME/prosthetics, gene therapies, CAR T-cell treatments, mental health services, and numerous surgical procedures. Billing teams must identify all affected services and update authorization workflows to avoid claim denials.
Anthem Blue Cross and Blue Shield (Virginia) is expanding its prior authorization (PA) requirements effective January 1, 2027, for national accounts. The policy now mandates pre-certification for numerous advanced procedures, diagnostic tests, durable medical equipment, gene therapies, CAR T-cell treatments, transplants, mental health services, and surgical procedures. This represents a comprehensive broadening of PA scope across multiple service categories.
Anthem Blue Cross and Blue Shield is expanding prior authorization (PA) requirements effective January 1, 2027, for Georgia commercial accounts. The policy adds comprehensive PA requirements across multiple service categories including advanced diagnostic testing (genetic testing, liquid biopsy, whole genome sequencing), specialized DME/prosthetics (robotic devices, AAC devices, bone growth stimulation), gene replacement therapies, CAR T-cell immunotherapy treatments, and numerous surgical procedures. Billing teams must update systems to require PA for these newly-covered services to avoid claim denials.
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