Medical Policy and Coding Updates

Effective April 8, 2026

Mobile Cardiac Telemetry and Implantable Loop Recorders, 2.02.510  Individual | Group
Title changed

• Policy title expanded from Mobile Cardiac Outpatient Telemetry to Mobile Cardiac Telemetry and Implantable Loop Recorders.

Medical necessity criteria added

• Implantable loop recorders may be considered medically necessary when criteria are met.
• Implantable loop recorders are subject to review per Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525.

Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525  Individual | Group
Medical necessity criteria added

• Mobile Cardiac Telemetry and Implantable Loop Recorders, 2.02.510 added as an included policy to indicated that implantable loop recorders only require review for Site of Service ASC for Select Surgical or Diagnostic Procedures in Adults.

Effective March 4, 2026

Electrophysiology (EP) studies, 2.02.517  Individual | Group
New policy

• Electrophysiology studies may be considered medically necessary when criteria are met.

Endovascular Stent Grafts for Abdominal Aortic Aneurysms, 7.01.601  Individual | Group
New policy

• The use of endoprostheses approved by the Food and Drug Administration (FDA) as a treatment of abdominal aortic aneurysms may be considered medically necessary when criteria are met.

Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570  Individual | Group
Medical necessity criteria updated

• Amondys 45 (casimersen), Duvyzat (givinostat), Exondys 51 (eteplirsen), Viltepso (vitolarsen), and Vyondys 53 (golodirsen) re-authorization criteria updated to require that documentation is provided that the individual is ambulatory without needing an assistive device (examples include cane, walker, and wheelchair).

Shoulder Arthrotomy, 7.01.605  Individual | Group
New policy

• Shoulder arthrotomy in adults may be considered medically necessary when criteria are met.

Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures, 11.01.525  Individual | Group
Title change

• Changed from Site of Service Ambulatory Service Center Select Surgical Procedures to Site of Service Ambulatory Service Center Select Surgical or Diagnostic Procedures.

Medical necessity criteria added

• Upper Gastrointestinal (UGI) Endoscopy for Adults, 2.01.533 added to list of surgical or diagnostic procedures that require review for Site of Service ASC for Select Surgical or Diagnostic Procedures.

Upper Gastrointestinal (UGI) Endoscopy in Adults, 2.01.533  Individual | Group
Title change

• Title changed from Upper Gastrointestinal (UGI) Endoscopy for Adults to Upper Gastrointestinal (UGI) Endoscopy in Adults.

Medical necessity criteria added

• Site of Service ASC Select Surgical Procedures criteria added.

Effective February 6, 2026

Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses, 1.01.506  Individual | Group
Medical necessity criteria added

• Second cranial orthosis as a treatment of persistent plagiocephaly after two months of use of the initial cranial orthosis may be considered medically necessary when criteria are met.

Gastroesophageal Reflux Surgery in Adults, 7.01.604  Individual | Group
New policy

• Laparoscopic esophagogastric fundoplication may be considered medically necessary when criteria are met.

Immune Checkpoint Inhibitors, 5.01.591  Individual | Group
Medical necessity criteria updated

• Criteria updates requiring that the tumors express PD-L1 (at least 1)
  • Yervoy (ipilimumab) for the treatment of esophageal squamous cell carcinoma (ESCC).
  • Opdivo (nivolumab) and Opdivo Qvantig (nivolumab and hyaluronidase-nvhy) for the treatment of gastric cancer, gastroesophageal junction cancer, and esophageal adenocarcinoma.
  • Opdivo Qvantig for the first-line treatment of unresectable advanced or metastatic ESCC.

Miscellaneous Oncology Drugs, 5.01.540  Individual | Group
Medical necessity criteria added

• Generic clofarabine and Clolar (clofarabine) for the treatment of relapsed or refractory acute lymphoblastic leukemia after at least two prior regimens in individuals aged one to 21 years.
• Ixempra (ixabepilone) when used in combination with capecitabine for the treatment of metastatic or locally advanced breast cancer when criteria are met.

Pharmacotherapy of Thrombocytopenia, 5.01.566  Individual | Group
Medical necessity criteria added

• WinRho SDF (Rh_o (D) Immune Globulin (Human)) for treatment of immune thrombocytopenia when criteria are met.
• WinRho SDF (Rh_o (D) Immune Globulin (Human)) for suppression of Rh isoimmunization in non-sensitized, Rh_o(D)-negative (D-negative) women with a Rh-incompatible pregnancy when criteria are met.

Shoulder Arthroscopy in Adults, 7.01.602  Individual | Group
New policy

• Shoulder arthroscopy in adults may be considered medically necessary for the indications noted when criteria are met.
• Thermal capsulorrhaphy is considered not medically necessary.
• Shoulder arthroscopy is subject to review per Site of Service Ambulatory Service Center (ASC) Select Surgical Procedures, 11.01.525.

Site of Service Ambulatory Service Center (ASC) Select Surgical Procedures, 11.01.525  Individual | Group
Medical necessity criteria added

• Shoulder arthroscopy in adults is subject to review per Site of Service ASC Select Surgical Procedures.

Effective January 2, 2026

Abdominal Wall Hernia in Adults, 7.01.600  Individual | Group
New policy

• Open or laparoscopic abdominal hernia repair may be considered medically necessary when criteria are met.

C3 and C5 Complement Inhibitors, 5.01.571  Individual | Group
Medical necessity criteria updated

• Bkemv (eculizumab-aeeb) and Soliris (eculizumab) updated from a preferred to a non-preferred product.
• Zilbrysq (zilucoplan) myasthenia gravis criteria updated to require trial with a preferred brand product first.

HER2 Inhibitors, 5.01.514  Individual | Group
Medical necessity criteria updated

• Ogivri (trastuzumab-dkst) updated from a non-preferred to a preferred product.
• Trastuzumab products (Herceptin, Herceptin Hylecta, Hercessi, Herzuma, and Ontruzant) updated to require trial with all preferred trastuzumab products.

Medical Necessity Criteria for Custom Open and Preferred Formularies, 5.01.647  Individual | Group
Medical necessity criteria updated

• Adalimumab-aaty (Yuflyma unbranded), Yuflyma (adalimumab-aaty), Avsola (infliximab-axxq), and Riabni (rituximab-arrx) updated from a non-preferred to a preferred product.
• Cyltezo (adalimumab-adbm) and Zymfentra (infliximab-dyyb) updated from a preferred to a non-preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria updated to require that the individual has had an inadequate response or intolerance to the preferred products for new starts.

Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502  Individual | Group
Medical necessity criteria updated

• Riabni (rituximab-arrx) updated from a non-preferred to a preferred product.
• Non-preferred rituximab products, Rituxan and Rituxan Hycela, updated to require trial with all preferred rituximab products.

Pharmacotherapy of Arthropathies, 5.01.550  Individual | Group
Medical necessity criteria updated

• Adalimumab-aaty (Yuflyma unbranded), Yuflyma (adalimumab-aaty), and Avsola (infliximab-axxq) updated from a non-preferred to a preferred product.
• Cyltezo (adalimumab-adbm) updated from a preferred to a non-preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria updated to require that the individual has had an inadequate response or intolerance to the preferred products for new starts.

Pharmacologic Treatment of Psoriasis, 5.01.629  Individual | Group
Medical necessity criteria updated

• Adalimumab-aaty (Yuflyma unbranded), Yuflyma (adalimumab-aaty), Yuflyma (adalimumab-aaty) and Avsola (infliximab-axxq) updated from a non-preferred to a preferred product.
• Cyltezo (adalimumab-adbm) and Zymfentra (infliximab-dyyb) updated from a preferred to a non-preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria updated to require that the individual has had an inadequate response or intolerance to the preferred products for new starts.

Pharmacologic Treatment of Psoriatic Arthritis, 5.01.645  Individual | Group
Medical necessity criteria updated

• Adalimumab-aaty (Yuflyma unbranded), Yuflyma (adalimumab-aaty) and Avsola (infliximab-axxq) updated from a non-preferred to a preferred product.
• Cyltezo (adalimumab-adbm) and Zymfentra (infliximab-dyyb) updated from a preferred to a non-preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria updated to require that the individual has had an inadequate response or intolerance to the preferred products for new starts.

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  Individual | Group
Medical necessity criteria updated

• Adalimumab-aaty (Yuflyma unbranded), Yuflyma (adalimumab-aaty), and Avsola (infliximab-axxq) updated from a non-preferred to a preferred product.
• Cyltezo (adalimumab-adbm) and Zymfentra (infliximab-dyyb) updated from a preferred to a non-preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria updated to require that the individual has had an inadequate response or intolerance to the preferred products for new starts.
• Omvoh (mirikizumab-mrkz) IV/SC updated from a preferred to a non-preferred product in sections two and three.

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  Individual | Group
Medical necessity criteria updated

• Adalimumab-aaty (Yuflyma unbranded), Yuflyma (adalimumab-aaty), and Avsola (infliximab-axxq) updated from a non-preferred to a preferred product.
• Cyltezo (adalimumab-adbm) and Zymfentra (infliximab-dyyb) updated from a preferred to a non-preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria updated to require that the individual has had an inadequate response or intolerance to the preferred products for new starts.
• Imaavy (nipocalimab-aahu) criteria updated to require trial with a preferred brand product first.
• Rystiggo (rozanolixizumab-noli) criteria brand step therapy requirement updated to remove Soliris (eculizumab) and add Epysqli (eculizumab-aagh) as an option.
• Fabhalta (iptacopan) and Filspari (sparsentan) criteria updated to require trial with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) and your urine protein-to-creatinine ratio is still 1.5 g/g or higher, or intolerance to an ACE inhibitor or ARB because of side effects or intolerance.

Rituximab: Non-oncologic and Miscellaneous Uses, 5.01.556  Individual | Group
Medical necessity criteria updated

• Adalimumab-aaty (Yuflyma unbranded), Yuflyma (adalimumab-aaty), Riabni (rituximab-arrx) and Avsola (infliximab-axxq) updated from a non-preferred to a preferred product.
• Cyltezo (adalimumab-adbm) updated from a preferred to a non-preferred product.
• Updated non-preferred rituximab products, Rituxan and Rituxan Hycela, to require trial with all preferred rituximab products.

Skilled Nursing Facility (SNF): Admission, Continued Stay, and Transition of Care Guideline, 11.01.510  Individual | Group
Medical necessity criteria added

• Service requirements and clinical appropriateness added to criteria.
• Admission conditions and continued stay conditions added to criteria.

Transcatheter Tricuspid Valve Repair or Replacement, 2.02.518  Individual | Group
New policy

• Transcatheter tricuspid edge-to-edge repair and transcatheter tricuspid valve replacement are considered investigational for all indications.

Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders, 5.01.620  Individual | Group
Medical necessity criteria added/updated

• Beovu (brolucizumab-dbll), Eylea (aflibercept), Eylea HD (aflibercept), Macugen (pegaptanib), and Susvimo (ranibizumab) criteria updated to require that the individual has had an inadequate response or intolerance to two preferred products for new starts.

Effective January 1, 2026

Auditory Brainstem Implant, 7.01.83  Individual | Group
Cochlear Implant, 7.01.586  Individual | Group
Hearing Aids (Excludes Implantable Devices), 1.01.528  Individual | Group
Implantable Bone-Conduction and Bone-Anchored Hearing Aids, 7.01.547  Individual | Group
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids, 7.01.84  Individual | Group
Medical necessity criteria added

• Benefit Application updated to include new WA Mandate, effective January 1, 2026:
  • Coverage for minors under 18 requires medical clearance within the past six months.
  • Clearance must come from either an otolaryngologist (initial hearing loss evaluation) or a licensed physician confirming no significant clinical change since that evaluation.

Effective for dates of service on and after January 1, 2026, site of service will be reviewed for advanced imaging services using the following criteria and administered through Carelon Medical Benefits Management, Inc. Site of Care for Advanced Imaging.

Hospital Outpatient Site of Care (HOPD)

HOPD is considered medically necessary when:

• Ancillary services are required and not available at freestanding centers in the same geographic area, including:
  • Moderate sedation, deep sedation, or general anesthesia.
  • Obstetrical or perinatology observation.
  • Support for establishing or maintaining intravenous access in patients with prior access difficulty.
  • Transfer or positioning assistance for bedbound patients or those with stage three to four decubitus ulcers.
  • Additional nursing or facility resources to support patients on contact or airborne precautions.
  • Rapid response capability for patients with high-risk medical conditions (examples include contrast allergy, implantable cardiac devices, ventilator dependence, and high risk of airway compromise).
• Specialized resources are needed and not available or infrequently performed at freestanding centers in the same area, such as:
  • Modalities requiring specialized hardware, software, or imaging protocols.
  • Expertise from subspecialty radiologists not available in the community, including pediatric radiology.
  • Technology such as open or large bore magnetic resonance imaging (MRI), for patients with claustrophobia, or equipment suitable for patients with very high body mass index.
• Continuity of care considerations apply, including:
  • Follow-up imaging previously performed at the same HOPD when technique consistency is needed for comparison.
  • Imaging required for pre-procedural planning when the procedure is scheduled at the same hospital.
  • Clinically significant delays in care would be expected if imaging were redirected outside the HOPD.

Effective for dates of service on and after January 1, 2026, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Radiology. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

• Combined Computed Tomography Angiography (CTA) Head and Neck exam can be billed using code 70471. This replaces billing the two exams separately:
  • CTA Head (70496)
  • CTA Neck (70498)
• This update makes it easier to handle requests for combined head and neck imaging.
• The system will still allow separate requests for CTA Head and CTA Neck (same as now).
• This is a temporary step until full guidelines for this exam are ready (planned for late 2026).

For questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines.

Revised medical policies
Effective January 1, 2026

Focal Treatments for Prostate Cancer, 8.01.61  Individual | Group
Medical necessity criteria removed

• Irreversible electroporation for prostate cancer moved to Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, Lung, or Prostate, 6.01.68.

Gender Transition/Affirmation Surgery and Related Services, 7.01.557  Individual | Group
Medical necessity criteria updated

• For appearance revision without pain or functional issues:
  • Added wording, “which verifies or demonstrates,” to allow documentation in various forms showing expected improvement in appearance and reduction of gender dysphoria.
• Mental health recommendations:
  • Simplified criteria for evidence that gender incongruence/dysphoria and desire to transition have persisted over time.
  • Reduced required elements for mental health recommendations when requesting gender-affirming surgery/procedures more than two years after a prior authorization.

Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung, 6.01.68  Individual | Group
Title changed

• Policy title updated from Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung to Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung, or Prostate.

Medical necessity criteria moved

• Irreversible electroporation for prostate cancer moved from Focal Treatments for Prostate Cancer, 8.01.61 to Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, Lung, or Prostate, 6.01.68.

Protein Biomarkers for Diagnosis and Risk Assessment of Prostate Cancer, 2.04.514  Individual | Group
Medical necessity criteria added

• MiCheck prostate test is considered investigational.

Remote Electrical Neuromodulation for Migraines, 7.01.171  Individual | Group
Medical necessity criteria updated

• Remote electrical neuromodulation updated from investigational to medically necessary in adults for prevention of migraine when criteria are met.
• Treatment of acute migraine remains investigational.

Transcranial Magnetic Stimulation as a Treatment of Depression and other Psychiatric and Neurologic Disorders, 2.01.526  Individual | Group
Medical necessity criteria removed

• Removed statements excluding accelerated theta burst stimulation.
  • Stanford Neuromodulation Therapy and Stanford Accelerated Intelligent Neuromodulation Therapy protocols remain investigational.

Medical necessity criteria added

• Electroencephalogram (EEG) brain mapping–guided transcranial magnetic stimulation (TMS) added to investigational list.

Medical necessity criteria updated

• Medication failure requirement modified: reasons can be stated for each medication or collectively.
• Expanded accelerated TMS coverage:
  • Removed hardship requirement for intensive courses.
  • Increased daily treatments to max five or 10 depending on TMS type, no increase in total treatments.
  • Concurrent functional magnetic resonance imaging (fMRI) or neuronavigation remains investigational.
• Updated maintenance TMS authorization:
  • Initial: up to 16 weeks (2/week) or 26 weeks (≤1/week).
  • Reauthorization: up to 26 weeks if improvement maintained
• Clarified vagus nerve stimulation (VNS) and TMS policy:
  • Vagus nerve stimulation with TMS is not medically necessary for psychiatric conditions, except when starting or undergoing maintenance TMS before VNS activation.
• Added note: If VNS device is deactivated, intensive TMS may be medically necessary if criteria are met.

Vagus Nerve Stimulation, 7.01.593  Individual | Group
Medical necessity criteria updated

• Clarified VNS and TMS policy:
  • Vagus nerve stimulation with TMS is not medically necessary for psychiatric conditions, except when starting or undergoing maintenance TMS before VNS activation.
• Added note: If VNS device is deactivated, intensive TMS may be medically necessary if criteria met.
• Modified medication failure requirement: reasons can be stated for each medication or collectively.

New pharmacy policies
Effective January 1, 2026

Antipsychotics, 5.01.659  Individual | Group
New policy

• Criteria for all Antipsychotics (Second Generation, “Atypicals”), Brands moved from Medical Necessity Criteria for Pharmacy Edits, 5.01.605 to Antipsychotics, 5.01.659.
  • Brand clozapine, brand clozapine ODT, and Mezofy (aripiprazole) removed from criteria.
• Separate policy sections for Metallic formulary plans, Essentials formulary plans, Open/Preferred/Select formulary plans.
• Formulary specific criteria for Second Generation Antipsychotics created for Metallic formulary and Essentials formulary plans.

Inhaled Corticosteroids, 5.01.660  Individual | Group
New policy

• Criteria for inhaled corticosteroids moved from Medical Necessity Criteria for Pharmacy Edits, 5.01.605 to Inhaled Corticosteroids, 5.01.660.
• Criteria updated to include Fluticasone Ellipta as a qualifying product and removed Fluticasone Propionate Diskus as a qualifying product.

Medical Necessity Criteria for the Essentials Formulary, 5.01.657  Individual | Group
New policy

• Eliquis (apixaban) and Eliquis Sprinkle (apixaban) may be considered medically necessary when criteria are met.

Revised pharmacy policies
Effective January 1, 2026

BRAF and MEK Inhibitors, 5.01.589  Individual | Group
Medical necessity criteria updated

• Gomekli (mirdametinib) criteria updated to require individuals have tried and had an inadequate response or intolerance to Koselugo (selumetinib) first.
• Koselugo (selumetinib) criteria updated to include coverage for individuals aged one year and older.

Medical Necessity Criteria for Pharmacy Edits, 5.01.605  Individual | Group
Medical necessity criteria added

• Arynta (lisdexamfetamine dimesylate) may be considered medically necessary for the treatment of binge eating disorder when criteria are met.
• Eurax (crotamiton) and Pruradik (crotamiton) may be considered medically necessary for the symptomatic treatment of pruritic skin when criteria are met.
• Marinol (dronabinol capsules) and Syndros (dronabinol oral solution) may be considered medically necessary for the treatment of nausea and vomiting associated with cancer or anorexia associated with weight loss in individuals with acquired immune deficiency syndrome when criteria are met.
• Brinsupri (brensocatib) may be considered medically necessary for the treatment of non-cystic fibrosis bronchiectasis when criteria are met.
• Soaanz (torsemide tablet) added to antihypertensive/diuretic drugs.
• Anzupgo (delgocitinib) may be considered medically necessary for the treatment of chronic hand eczema when criteria are met.
• Lynkuet (elinzanetant) added with a quantity limit of 60 capsules per 30 days.

Medical necessity criteria updated

• Nocdurna (desmopressin sublingual tablets) criteria updated to limit the prescribed quantity to one sublingual tablet per day.
• Alinia (nitazoxanide) and generic nitazoxanide criteria updated to include a daily dose limit.
• Sirturo (bedaquiline) criteria updated to include coverage for individuals aged two years and older and weighing at least eight kg.
• Emend (aprepitant) criteria updated to include a quantity limit per fill.
• Linzess (linaclotide) criteria updated for the treatment of irritable bowel syndrome with constipation to include individuals aged seven years and older.
• Arixtra (fondaparinux), Fragmin (dalteparin), and Lovenox (enoxaparin) criteria updated to require the individual has tried and had an inadequate response or intolerance to generic enoxaparin and generic fondaparinux.
• Kerendia (finerenone) criteria updated for the treatment of chronic kidney disease and heart failure limiting the prescribed quantity to one tablet per day.
• Cequa, Miebo, Restasis, Tryptyr, Vevye, and Xiidra criteria updated to add a prescribed quantity limit per 30 days.
• Palforzia criteria updated to limit the prescribed quantity to six capsules per day.
• Alkindi Sprinkle criteria updated to add a prescribed quantity limit per 30 days.
• Adapalene/benzoyl peroxide, Epiduo, and Epiduo Forte criteria updated to include quantity limits.
• Vyvanse criteria updated to include a prescribed quantity limit per 30 days.

Medical necessity criteria removed

• Aczone removed from Brand Topical Acne or Rosacea Products.
• Accuretic, Lotensin HCT, Lotrel, Prestalia, Vaseretic, and Zestoretic removed from ACEI Combinations, Brand.
• Adderall, Adderall XR, Adzenys ER, Adzenys XR-ODT, Desoxyn, Dexedrine, Evekeo, and Zenzedi removed from ADHD Drugs, Brands.
• Azor, brand levamlodipine, Caduet, Cardizem, Cardizem CD, Cardizem LA, Conjupri, Exforge, Exforge HCT, Lotrel, Norvasc, Prestalia, Procardia XL, Sular, Tiazac, Tribenzor, and Verelan PM removed from Calcium Channel Blockers.
• Klaron removed from Topical Sebolonrrheic Dermatitis Agents, Brand.
• Accupril, Altace, Epaned, Lotensin, Qbrelis, Vasotec, and Zestril removed from ACEIs, Brand.
• Generic pyrimethamine removed from Antiparasitic Agents.
• Consensi removed from Combination Medications (Misc.).
• Atacand, Avapro, Benicar, Cozaar, Diovan, Edarbi, Micardis, Tekturna, and Valsartan solution removed from Angiotensin II Receptor Blockers (ARBs), Brand.
• Acanya and Cleocin T and PR benzoyl peroxide 7% wash removed from Brand Topical Acne or Rosacea Products.
• Celebrex and Dolobid removed from Brand Oral NSAIDs.
• Lopressor removed from Beta Blockers, Oral.
• Criteria for all Antipsychotics (Second Generation, “Atypicals”), Brands moved from Medical Necessity Criteria for Pharmacy Edits, 5.01.605 to Antipsychotics, 5.01.659.
• Criteria for inhaled corticosteroids moved from Medical Necessity Criteria for Pharmacy Edits, 5.01.605 to Inhaled Corticosteroids, 5.01.660.

Migraine and Cluster Headache Medications, 5.01.503  Individual | Group
Medical necessity criteria updated

• Criteria for Amerge (naratriptan), Frova (frovatriptan), Imitrex (sumatriptan), Maxalt (rizatriptan), Maxalt MLT (rizatriptan), Relpax (eletriptan), Tosymra (sumatriptan), Zomig (zolmitriptan) tablets, and Zomig (zolmitriptan) five mg nasal spray updated to remove requirement to use generic triptans first.
• Quantity for Elyxyb (celecoxib oral solution) updated from 18 bottles per 30 days to 12 bottles per 28 days.
• Migranal (dihydroergotamine) nasal spray criteria updated to remove requirement to use generic dihydroergotamine nasal spray first.

Medical necessity criteria added

• Generic ergotamine-caffeine tablets and Migergot (ergotamine-caffeine) may be considered medically necessary for the acute treatment of migraine headaches when criteria are met.

Medical necessity criteria removed

• Ergomar (ergotamine) criteria removed.

Miscellaneous Oncology Drugs, 5.01.540  Individual | Group
Medical necessity criteria updated

• Inrebic (fedratinib), Lynparza (olaparib), Retevmo (selpercatinib) criteria updated to include a quantity limit.

Medical necessity criteria added

• Blenrep (belantamab mafodotin-blmf) may be considered medically necessary for the treatment of relapsed or refractory multiple myeloma when criteria are met.
• Cosmegen (dactinomycin) may be considered medically necessary when criteria are met.

Medical necessity criteria removed

• Kisqali Femara Co-Pack removed as drug was withdrawn from the market.
• Casodex (bicalutamide), Eulexin (flutamide), Nilandron (nilutamide), generic nilutamide, and quantity limits moved to Drug Quantity Management, 5.01.656.

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  Individual | Group
Medical necessity criteria removed

• Removed reference to preferred formulary (Formulary ID: 6064; Rx Plan G3), as it is no longer available.

Medical necessity criteria updated

• Lupkynis (voclosporin) and Benlysta (belimumab) SC/IV criteria updated to clarify that the medication will not be used concurrently with Gazyva (obinutuzumab).

Selective Estrogen Receptor Modulators and Down Regulators, 5.01.618  Individual | Group
Medical necessity criteria added

• Inluriyo (imlunestrant) may be considered medically necessary for the treatment of estrogen receptor-positive, human epidermal growth factor receptor 2-negative, ESR1- mutated advanced or metastatic breast cancer when criteria are met.

Medical necessity criteria removed

• Arimidex (anastrozole), Aromasin (exemestane), Evista (raloxifene), and quantity limits moved to Drug Quantity Management, 5.01.656.

Spravato (esketamine) Nasal Spray, 5.01.609  Individual | Group
Medical necessity criteria updated

• Criterion added confirming no current or past bipolar disorder and no history of manic or hypomanic episodes.
• Substance use criterion updated to require remission or complete abstinence for at least one month, with agreement to remain abstinent.
• Option added for temporary increase in treatment frequency to twice weekly if depression worsens during maintenance.
• Clarified that improvement during maintenance can be shown by symptom documentation or standardized depression rating scales.
• Modified medication failure requirement: reasons for failure can be stated for each medication individually or collectively for all failed medications.

Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517  Individual | Group
Medical necessity criteria updated

• Revlimid (lenalidomide) to require that the individual has tried and had an inadequate response or intolerance to generic lenalidomide for all indications.

Effective January 1, 2026

Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis, 2.04.127
Policy archived

• Policy archived due to this diagnostic procedure being standard of care.

No updates this month.

Added codes
Effective April 8, 2026

Mobile Cardiac Outpatient Telemetry and Implantable Loop Recorders, 2.01.510  Individual | Group
Now requires review for medical necessity and prior authorization, in addition to review for site of service.

33285, E0616

Now requires review for medical necessity.

C1764

Site of Service Ambuatory Service Center (ASC): Select Surgical Procedures in Adults, 11.01.525  Individual | Group
Now requires review for medical necessity and prior authorization, in addition to review for site of service.

33285, E0616

Effective March 4, 2026

Electrophysiology (EP) Studies, 2.02.517  Individual | Group
Now requires review for medical necessity and prior authorization.

93609, 93613, 93619, 93620, 93621, 93622, 93624, 93653, 93654

Endovascular Stent Grafts for Abdominal Aortic Aneurysms, 7.01.601  Individual | Group
Now requires review for medical necessity and prior authorization.

34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708, 34710, 34711, 34717, 34718, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848

Non-covered Services and Procedures, 10.01.517  Individual | Group
Now non-covered.

0751T, 0752T, 0754T, 0755T, 0757T, 0758T, 0759T, 0760T, 0761T, 0762T, 0763T

Shoulder Arthrotomy in Adults, 7.01.605  Individual | Group
Now requires review for medical necessity and prior authorization.

20670, 20680, 23040, 23044, 23101, 23105, 23106, 23107, 23120, 23130, 23410, 23412, 23415, 23420, 23450, 23455 , 23460, 23462 , 23465, 23466, 23550, 23552, 23585, 23615, 23616, 23630, 23660, 23670, 23680

Site of Service Ambulatory Service Center (ASC): Select Surgical Procedures for Adults, 11.01.525  Individual | Group
Now requires review for medical necessity, in addition to current review for site of service and prior authorization.

43235, 43238, 43239, 43242

Effective February 6, 2026

Cosmetic and Reconstructive Services, 10.01.514  Individual | Group
Requires review for medical necessity and prior authorization.

21086, V2623, V2629

Gastroesophageal Reflux Surgery in Adults, 7.01.604  Individual | Group
Requires review for medical necessity and prior authorization.

43280, 43281, 43282

Miscellaneous Oncology Drugs, 5.01.540  Individual | Group
Requires review for medical necessity and prior authorization.

J9027, J9207

Pharmacotherapy of Thrombocytopenia, 5.01.566  Individual | Group
Requires review for medical necessity and prior authorization.

J2791

Shoulder Arthroscopy in Adults, 7.01.602  Individual | Group
Requires review for medical necessity and prior authorization.

29805, 29806, 29807, 29819, 29820-29828

Site of Service Ambulatory Service Center (ASC) Select Surgical Procedures, 11.01.525  Individual | Group
Requires review for site of service, in addition to current review for medical necessity and prior authorization.

29805, 29806, 29807, 29819-29828

Effective January 2, 2026

Abdominal Wall Hernias, 7.01.600  Individual | Group
Now requires review for medical necessity and prior authorization.

49591, 49593, 49595, 49613, 49615, 49617, 49659

Pharmacotherapy of Cushing's Disease and Acromegaly, 5.01.548  Individual | Group
Now requires review for medical necessity and prior authorization.

J1932

Transcatheter Tricuspid Valve Repair or Replacement, 2.02.518  Individual | Group
Considered investigational.

0569T, 0570T, 0646T

Effective January 1, 2026

Amniotic Membrane and Amniotic Fluid, 5.01.583  Individual | Group
Now considered investigational.

Q4398, Q4399, Q4400, Q4401, Q4402, Q4403, Q4404, Q4405, Q4406, Q4407, Q4408, Q4409, Q4410, Q4411, Q4412, Q4413, Q4414, Q4415, Q4416, Q4417, Q4420

Antibody-Drug Conjugates, 5.01.582  Individual | Group
Now requires review for medical necessity and prior authorization.

J9326

Automated Percutaneous and Percutaneous Endoscopic Discectomy, 7.01.18  Individual | Group
Image-Guided Minimally Invasive Decompresson for Spinal Stenosis, 7.01.126  Individual | Group
Now considered investigational.

62330, 62331

Bariatric Surgery, 7.01.516  Individual | Group
Now considered investigational.

43889

Bioengineered Skin and Soft Tissue Substitutes, 7.01.582  Individual | Group
Now considered investigational.

Q4431, Q4432, Q4433

Bispecific Antibodies, 5.01.650  Individual | Group
Now requires review for medical necessity and prior authorization.

C9307

Carelon Benefit Management Guidelines, Advanced Imaging and Site of Care
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

70336, 70450, 70471, 70473, 70491, 70480, 70486, 70490, 70496, 70498, 70540, 70544, 70547, 70551, 71250, 71271, 71275, 71550, 71555, 72125, 72128, 72131, 72141, 72146, 72148, 72159, 72191, 72192, 72195, 72198, 73200, 73206, 73218, 73221, 73225, 73700, 73706, 73721, 73725, 74150,  74174, 74175, 74176, 74181, 74185, 74263, 75635, 77078

Carelon Benefit Management Guidelines, Genetic Testing
Now requires review for medical necessity and prior authorization.

0605U, 0611U, 0612U, 0613U, 81354, 81524

Carpal Tunnel Release: Surgical Techniques, 7.01.595  Individual | Group
Now considered investigational.

64728

Cooling Devices Used in the Outpatient Setting, 1.01.538  Individual | Group
Now requires review for medical necessity.

C9810, C9817

Coronary Angiography for Known or Suspected Coronary Artery Disease in Adults, 2.02.507  Individual | Group
Now requires review for medical necessity.

C7568, C7570

Drug Testing in Pain Management and Substance Use Disorder Treatment Settings, 2.04.513  Individual | Group
Now considered investigational.

0603U

Electronic Brachytherapy for Nonmelanoma Skin Cancer, 8.01.62  Individual | Group
Now considered investigational.

77436, 77437, 77438, 77439

Gene Therapies for Cerebral Andrenoleukodystrophy, 6.01.534  Individual | Group
Now requires review for medical necessity and prior authorization.

J3387

Hearing Aids (Excludes Implantable Devices), 1.01.528  Individual | Group
Benefit managed only

92628, 92629, 92631, 92632, 92634, 92635, 92636, 92637, 92638, 92639, 92641, and 92642

Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain and Other Conditions, 7.01.574  Individual | Group
Now considered investigational.

0988T, 0989T

Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, Lung, or Prostate, 6.01.68   Individual | Group
Now considered investigational.

47384, 55877

Laboratory Testing Investigational Services, 2.04.520  Individual | Group
Now non-covered.

0600U, 0601U, 0602U, 0606U, 0607U, 0608U, 0609U

Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomy in Adults, 7.01.551  Individual | Group
Now requires review for medical necessity, in addition to current review for site of service and prior authorization.

63032

Medical Necessity Criteria for Pharmacy Edits, 5.01.605  Individual | Group
Now requires review for medical necessity and prior authorization.

J1073

Deep Brain Stimulation, 7.01.63  Individual | Group
Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain, 7.01.574  Individual | Group
Gastric Electrical Stimulation, 7.01.522  Individual | Group
Occipital Nerve Stimulation, 7.01.125  Individual | Group
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy, 7.01.143  Individual | Group
Sacral Nerve Neuromodulation Stimulation, 7.01.69  Individual | Group
Spinal Cord and Dorsal Root Ganglion Stimulation, 7.01.546  Individual | Group
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.554  Individual | Group
Vagus Nerve Stimulation, 7.01.593  Individual | Group
Now requires review for medical necessity.

C1607

Non-Covered Experimental and Investigational Services, 10.01.533  Individual | Group
Now non-covered.

0990T, 0991T, 0992T, 0993T, 0994T, 0995T, 0996T, 0997T, 0998T, 0999T, 1000T, 1001T, 1002T, 1004T, 1005T, 1006T, 1007T, 1008T, 1009T, 1010T ,1011T, 1013T, 1014T, 1015T, 1016T, 1017T, 1018T, 27458, 27713, 52443, 75577, 94470, C9761, E0446

Non-Covered Services, 10.01.517  Individual | Group
Now non-covered.

E0420, E0244, E0245, 97007, 97008, 97009

Percutaneous Coronary Intervention, Angioplasty, Non-Emergent in Adults, 2.01.508  Individual | Group
Now requires review for medical necessity and prior authorization.

92930, 92945

Now requires review for medical necessity.

C7569, C7571

Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome, 2.01.106  Individual | Group
Now considered investigational.

64567

Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease, 7.01.594  Individual | Group
Now requires review for medical necessity and prior authorization.

37254, 37255, 37256, 37257, 37258, 37259, 37260, 37261, 37263, 37264, 37265, 37266, 37267, 37268, 37269, 37270, 37271, 37272, 37273, 37274, 37275, 37276, 32727, 37278, 37280, 37281, 37282, 37283, 37284, 37285, 37286, 37287, 37288, 37289, 37290, 37291, 37292, 37293, 37294, 37295, 37296, 37297, 37298, 37299

Now considered investigational.

37262, 37279

Pharmacologic Treatment of Epidermolysis Bullosa, 5.01.635  Individual | Group
Now requires review for medical necessity and prior authorization.

J3389

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  Individual | Group
Now requires review for medical necessity and prior authorization.

J9256

Preventive Care Services, 10.01.523  Individual | Group
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

77046, 77047, 77048, 77049

Now covered as part of the standard benefit.

G0023, G0024

Site of Service: Drugs and Biologic Agents, 11.01.523  Individual | Group
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J1743, J9289

Spravato (esketamine) Nasal Spray, 5.01.609  Individual | Group
Now requires review for medical necessity and prior authorization.

J0013

Surgical Treatments for Lymphedema and Lipedema, 7.01.567  Individual | Group
Now considered investigational.

1019T

Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation for Benign Prostatic Hyperplasia, 2.01.544  Individual | Group
Now requires review for medical necessity and prior authorization.

52597

Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517  Individual | Group
Now requires review for medical necessity and prior authorization.

Q5160

Revised codes
Effective March 4, 2026

Upper Gastrointestinal (UGI) Endoscopy for Adults, 2.01.533  Individual | Group
Now requires review for medical necessity, in addition to current review for site of service and prior authorization.

43235, 43238, 43239, 43242

Effective January 1, 2026

Microwave Tumor Ablation, 7.01.033  Individual | Group
No longer considered investigational. Now requires review for medical necessity and prior authorization.

0944T

No longer requires review for medical necessity. Now requires review for investigational and prior authorization.

60660, 60661

Remote Electrical Neuromodulation for Migraines, 7.01.171  Individual | Group
No longer considered investigational. Now requires review for medical necessity and prior authorization.

A4540

No longer requires review for medical necessity. Now requires review for investigational and prior authorization.

60660, 60661

Removed codes
Effective January 1, 2026

Antibody-Drug Conjugates, 5.01.582  Individual | Group
Code Terminated

C9306

Bariatric Surgery, 7.01.516  Individual | Group
Code Terminated

C9784

Carelon Benefit Management Guidelines, Advanced Imaging
Code Terminated

0042T

Carelon Benefit Management Guidelines, Genetic Testing
Code Terminated

0033U, 0131U, 0132U, 0135U, 0508U, 0509U, 0544U

Carelon Benefit Management Guidelines, Radiation Oncology
Code Terminated

77385, 77386, 77014

Electronic Brachytherapy for Nonmelanoma Skin Cancer, 8.01.62  Individual | Group
Code Terminated

0394T

Evaluation of Biomarkers for Alzheimers Disease, 2.04.521  Individual | Group
Code Terminated

0361U, 0551U

Image-Guided Minimally Invasive Decompresson for Spinal Stenosis, 7.01.126  Individual | Group
Code Terminated

0275T

Immune Globulin Therapy, 8.01.503  Individual | Group
Site of Service: Drugs and Biologic Agents, 11.01.523  Individual | Group
Code Terminated

J1572

Medical Necessity Criteria for Pharmacy Edits, 5.01.605  Individual | Group
Code Terminated

J0889

Microwave Tumor Ablation, 7.01.133  Individual | Group
Code Terminated

C9751

Miscellaneous Oncology Drugs, 5.01.540  Individual | Group
Code Terminated

J9019, J9245

Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis, 2.04.127  Individual | Group
No longer requires review.

0330U, 0505U, 0557U, 81513, 81514, 81515

Non-Covered Experimental and Investigational Services, 10.01.533  Individual | Group
Code Terminated

0619T, 0623T, 0624T, 0625T, 0626T

Non-Covered Services, 10.01.517  Individual | Group
No longer requires review.

G0023, G0024

Code Terminated

0663T

Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitues) Used with Autologous Bone Marrow, 8.01.52  Individual | Group
No longer requires review.

0263T, 0264T, 0265T, 38241

Percutaneous Coronary Intervention, Angioplasty, Non-Emergent in Adults, 2.02.508  Individual | Group
Code Terminated

92921, 92925, 92929, 92934, 92938, 92944

Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome, 2.01.106  Individual | Group
Code Terminated

0720T

Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease, 7.01.594  Individual | Group
Code Terminated

7220, 37221, 37222, 37223, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234, 37235

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  Individual | Group
Code Terminated

C9305

Spravato (esketamine) Nasal Spray, 5.01.609  Individual | Group
Code Terminated

S0013

Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation for Benign Prostatic Hyperplasia, 2.01.544  Individual | Group
Code Terminated

0421T

Effective February 6, 2026

Routine Test Management Policies
New policies

• Fifty routine test management (RTM) policies (see list below).
• The policies are intended to support claims editing for laboratory services, not prior authorization, and exclude genetic testing, which will continue to be reviewed through  Carelon Medical Benefits Management.
  • These policies are managed through claims edits to handle straightforward, rule-based criteria (examples include diagnosis matching, and frequency limits), not complex clinical decisions.

Allergen Testing, 15.01.001  Group
Biomarker Testing for Autoimmune Rheumatic Disease, 15.01.040  Group
Biomarkers for Myocardial Infarction and Chronic Heart Failure, 15.01.034  Group
Bone Turnover Markers Testing, 15.01.011  Group
Celiac Disease Testing, 15.01.031  Group
Coronavirus Testing in the Outpatient Setting, 15.01.014  Group
Diagnosis of Idiopathic Environmental Intolerance, 15.01.036  Group
Diagnostic Testing of Influenza, 15.01.018  Group
Diagnostic Testing of Iron Homeostasis & Metabolism, 15.01.030  Group
Epithelial Cell Cytology in Breast Cancer Risk Assessment, 15.01.033  Group
Evaluation of Dry Eyes, 15.01.007  Group
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing, 15.01.039  Group
Fecal Calprotectin Testing in Adults, 15.01.012  Group
Flow Cytometry, 15.01.002  Group
Folate Testing, 15.01.024  Group
Gamma-glutamyl Transferase, 15.01.021  Group
General Inflammation Testing, 15.01.019  Group
Helicobacter Pylori Testing, 15.01.032  Group
Human Immunodeficiency Virus (HIV), 15.01.02715.01.016
Identification Of Microorganisms Using Nucleic Acid Probes, 15.01.016  Group
Immune Cell Function Assay, 15.01.010  Group
Immunohistochemistry, 15.01.005  Group
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies, 15.01.035  Group
In Vitro Chemoresistance and Chemosensitivity Assays, 15.01.038  Group
Intracellular Micronutrient Analysis, 15.01.041  Group
Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease, 15.01.051  Group
Lyme Disease Testing, 15.01.008  Group
Metabolite Markers of Thiopurines Testing, 15.01.009  Group
Nerve Fiber Density Testing, 15.01.022  Group
Onychomycosis Testing, 15.01.037  Group
Pancreatic Enzyme Testing for Acute Pancreatitis, 15.01.025  Group
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing, 15.01.006  Group
Pathogen Panel Testing, 15.01.043  Group
Prescription Medication and Illicit Drug Testing in the Outpatient Setting, 15.01.046  Group
Prostate Biopsy Specimen Analysis, 15.01.045  Group
Salivary Hormone Testing, 15.01.028  Group
Serum Biomarker Testing for Multiple Sclerosis and related Neurologic Disease, 15.01.052  Group
Serum Testing for Evidence of Mild Traumatic Brain Injury, 15.01.023  Group
Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease, 15.01.013Group
Serum Tumor Markers for Malignancies, 15.01.042  Group
Testing For Alpha-1 Antitrypsin Deficiency, 15.01.048  Group
Testing for Vector-borne Infections, 15.01.026  Group
Testing of Homocysteine Metabolism-Related Conditions, 15.01.049  Group
Testosterone, 15.01.017  Group
Therapeutic Drug Monitoring for 5-Fluorouracil, 15.01.044  Group
Thyroid Disease Testing, 15.01.003  Group
Urinary Tumor Markers for Bladder Cancer, 15.01.050  Group
Urine Culture Testing for Bacteria, 15.01.015  Group
Venous and Arterial Thrombosis Risk Testing, 15.01.047  Group
Vitamin B12 And Methylmalonic Acid Testing, 15.01.029  Group

No updates this month.

Effective February 6, 2026

Drug Testing in Pain Management and Substance Abuse Disorder, 2.04.513
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis, 2.04.26
Intracellular Micronutrient Testing, 2.04.73
Nutrient/Nutrional Panel Testing, 2.04.136
Policies deleted

• Drug Testing in Pain Management and Substance Abuse Disorder, 2.04.513 deleted and replaced with routine test management (RTM) policy Prescription Medication and Illicit Drug Testing in the Outpatient Setting, 15.01.046.
• Fecal Analysis in the Diagnosis of Intestinal Dysbiosis, 2.04.26 deleted and replaced with  RTM policy Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing, 15.01.039.
• Intracellular Micronutrient Testing, 2.04.73 deleted and replaced with RTM policy Intracellular Micronutrient Analysis, 15.01.041.
• Nutrient/Nutrional Panel Testing, 2.04.136 deleted and replaced with RTM policy Intracellular Micronutrient Analysis, 15.01.041.

No updates this month.

Removed codes
Effective December 1, 2026

Miscellaneous Oncology Drugs, 5.01.540  Group
No longer requires review.

J9245

Effective March 4, 2026

Laryngeal Injection for Vocal Cord Augmentation, 2.01.541  Individual
Title changed

• Title changed from Laryngeal Injection for Vocal Cord Augmentation Augmentation to Office-Based Laryngeal Procedures.

Medical necessity criteria updated

• Additional procedures and diagnoses added; policy scope aligned with procedures performed in the office setting.

Effective January 2, 2026

High-Resolution Anoscopy, 2.01.539  Individual
Medical necessity criteria added

• Indications added:
  • Symptom-driven and therapeutic indications including rectal bleeding, anal pain, fistula, trauma, foreign body retrieval, hemorrhoid treatment (rubber band ligation), and post-treatment surveillance for anal carcinoma.
  • High risk Human Papillomavirus (hrHPV)-based screening triggers including immediate high-resolution anoscopy for hrHPV-positive results (including HPV16+) and specific cytology/hrHPV combinations, even when cytology is negative for intraepithelial lesion or malignancy.
• Contraindications added:
  • Patient-related limitations including the inability to tolerate the exam due to discomfort, anxiety, or apprehension.
  • Clinical safety concerns including significant active bleeding or presence of a friable mass that could be damaged, bleed, or irritated by the rigid anoscope.

No updates this month.

No updates this month.

No updates this month.

No updates this month.