Medical Policy and Coding Updates

Effective September 19, 2026

Effective for dates of service on and after September 19, 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.

Updates by section

Imaging of the Brain

• Expanded indications for computed tomography (CT) cerebral perfusion

Imaging of the Extremities

• Allowances management without requiring repeat x-ray for osteomyelitis, avascular necrosis
• Specification for triangular fibrocartilage complex instability bypassing requirement for conservative management
• Meniscal tear knee: Added allowances following meniscal repair
• Knee arthroplasty pre-surgical imaging: Expanded allowance when conventional arthroplasty not feasible; specification of deformity criteria

Imaging of the Spine

• Modality specifications for spinal infection and axial spondyloarthropathy
• Spine pain/radiculopathy: Condensed content, added frequency limitation

Nuclear Medicine Imaging

• Condensed content for osseous tumors and established malignancy/neoplasm
• Added content for radioembolization scintigraphy using non-liver specific CPT codes

Vascular Imaging

• Separated content into 2 guidelines: Advanced Imaging for Vascular Indications and Vascular Ultrasound and Physiologic Testing

Advanced Imaging for Vascular Indications

• General
  • Added indication for positron emission tomography (PET)/CT for vasculitis
• Brain, Head and Neck
  • Added allowances for newly added computed tomographic angiography (CTA) Head/Neck code for aneurysm, arteriovenous malformation, dissection, fibromuscular dysplasia, pulsatile tinnitus, procedure related imaging, stenosis or occlusion, and signs/symptoms/abnormal imaging
  • Duplex ultrasound required prior to CTA/ magnetic resonance angiography (MRA) for all signs or symptoms of stroke/transient ischemic attack that have been present more than 30 days 
  • Removed allowance for advanced vascular imaging for syncope to align with professional society guidelines
  • Added criterion for CTA/MRA for evidence of stroke on brain imaging
  • Added criterion for CTA/MRA for evaluation of subclavian steal syndrome
• Chest
  • Added surveillance intervals following endovascular repair for thoracic aortic dissection
  • Added criteria for surveillance after repair of thoracic aortic aneurysm
• Abdomen and Pelvis
  • Reduced required number of antihypertensive medications from 4 to 3 for renal artery stenosis to treat refractory hypertension to align with the European Society for Vascular Surgery guideline recommendations
  • Added surveillance indication after endovascular revascularization of the aortoiliac vessels
  • Added criterion for imaging of pelvic venous disease
• Upper Extremity
  • Modified post-revascularization imaging intervals in upper extremity peripheral arterial disease to align with lower extremity criteria
• Lower Extremity
  • Aligned the post-revascularization intervals for surgical and endovascular revascularization in peripheral arterial disease

Imaging of the Heart

• Cardiac CT with Quantitative Evaluation of Coronary Calcification
  • When coronary artery calcium is used for go/no go statin decision and score is zero, recommend repeat study in 5-10 years to reevaluate statin question (provided other criteria still met)
• Magnetic resonance imaging (MRI) Cardiac
  • Expansion of criteria for when to allow cardiac MRI for hypertrophic and non-compaction cardiomyopathy
• PET Myocardial Imaging
  • Clarification of language in indications for PET Perfusion Imaging

Effective for dates of service on and after September 19, 2026, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Sleep Disorder Management. 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.

Polysomnography

• Removed respiratory disturbance event definition
• Clarified suspected sleep disorder other than obstructed sleep apnea
• Added criteria to align with best practices for established sleep disorder (obstructed sleep apnea or other) – follow-up laboratory studies
• Added criteria for nocturnal seizures for In-lab (attended) sleep studies in non-adult patients (age 17 years or younger)

Bi-Level Positive Airway Pressure Devices

• Aligned criteria  with recently published American Academy of Sleep Medicine updated clinical practice guideline for treatment of central sleep apnea - Journal of Clinical Sleep Medicine. 2025.

Effective for dates of service on and after September 19, 2026, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Genetic Testing. 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.

All Genetic Testing guidelines

• General Requirements:
  • Added statement that testing be performed in a Clinical Laboratory Improvement Amendments certified lab accredited by the College of American Pathologists

Carrier Screening in the Reproductive Setting

• Clarified screening limited to once per lifetime for a given gene instead of for a given condition
• Removed exclusion (clarification): molecular screening for conditions where nonmolecular techniques can be used

Prenatal Screening using Cell-free DNA

• Added medically necessary indications for fetal red blood cell antigen screening using cell-free deoxyribonucleic acid (cfDNA)
• Clarified scenarios on use of cfDNA screening considered not medically necessary, including removal of Rhesus D antigen and/or other fetal red blood cell antigens

Genetic Testing for Inherited Conditions

• General Requirements:
  • Clarified that germline genetic testing is limited to once per lifetime for a given gene except when individual is inadequately tested
  • Allowed testing for an inherited condition per member health plan drug-specific policy requirements
  • Clarified that multigene panel testing is considered not medically necessary when either whole exome or whole genome sequencing is being or has been performed
• Cardiac conditions:
  • Hereditary arrhythmia syndromes: clarifications
  • Hereditary cardiomyopathy syndromes: removed age restriction in symptomatic individuals and allow for genetic testing of either symptomatic or presymptomatic individuals with a family history 
  • Hereditary aortopathies: clarifications
• Primary mitochondrial diseases: targeted gene panel expanded from <25 to <30 genes
• Thrombophilia testing:
  • Added two criteria for individuals with a venous thromboembolism (VTE): Pregnancy or postpartum up to 6 weeks, or estrogen exposure
  • Added a criterion for individuals with or without a VTE and low activated protein C resistance activity
  • Edited one criterion for individuals without a VTE contemplating pregnancy and first-degree relative with VTE and high-risk thrombophilia
  • Added criteria for individuals without a VTE: Pregnant or postpartum and a first-degree relative with a history of VTE and high-risk thrombophilia or cancer receiving chemotherapy at low or intermediate risk of thrombosis and a first-degree relative with a history of VTE
  • Clarified scenarios considered not medically necessary
• Biomarker testing for rejection in solid organ transplantation
  • For individuals ≥15 years of age post-cardiac transplantation: Testing is allowed beginning at 2 months post-transplant (reduced from 6 months), with testing frequency permitted at 2-month intervals (reduced from 3 months) between 2 and 12 months after transplant.
  • Clarified additional scenarios and related tests for gene expression profiling, donor-derived cell-free DNA (dd-cfDNA), and MicroRNA testing considered not medically necessary

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

Effective September 4, 2026

Negative Pressure Wound Therapy (NPWT) Devices in Adults, 1.01.508  Individual | Group
Title Change

• Title changed from Negative Pressure Wound Therapy (NPWT) Devices in Adults to Negative Pressure Wound Therapy (NPWT) Devices.

Medical necessity criteria updated

• Eliminated the age restriction limiting the policy to adults aged 19 and older.

Investigational criteria added

• The use of NPWT systems is considered investigational in individuals aged 11 years and younger.

Orthognathic Surgery, 9.02.501  Individual | Group
Medical necessity criteria updated

• Congenital anomalies now include Noonan syndrome and revised Pierre Robin syndrome to Pierre Robin sequence.

Investigational criteria added

• Three-dimensional virtual treatment planning or computer-aided three-dimensional simulation and navigation in orthognathic surgery is considered investigational.

Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence, 1.01.17  Individual | Group
New policy

• Electrical or magnetic stimulation of the pelvic floor muscles as a treatment for urinary or fecal incontinence is considered investigational.

Shoulder Arthrotomy in Adults, 7.01.605  Individual | Group
Medical necessity criteria updated

• Conservative management requirements were modified to include both a medication trial with failure and a trial with failure of physical measures for the indications:
  • Decompression of subacromial space or acromioplasty for rotator cuff tendonitis
  • Full thickness rotator cuff repair
  • Resection of distal clavicle
  • Shoulder dislocation
  • Synovectomy
• Additional testing now required for the following indications:
  • Decompression of subacromial space or acromioplasty for rotator cuff tendonitis,
  • Full thickness rotator cuff repair
  • Resection of distal clavicle
  • Shoulder dislocation

Medical necessity criteria removed

• Criteria for the following indications no longer included in policy:
  • Acromioclavicular (AC) separation with recent traumatic event
  • Shoulder pain, deformity, partial thickness rotator cuff repair
  • Removal of intra-articular osteochondral lesion or loose body
  • Recurrent shoulder dislocation (greater than two years, less than two years)
  • Initial or recurrent shoulder dislocation with Bankart, Hill-Sachs, or anterior glenoid rim fracture
  • Shoulder fracture repair
  • Shoulder hardware removal

Effective August 7, 2026

Denosumab Products, 5.01.658  Individual | Group
Medical necessity criteria updated

• Bildyos (denosumab-nxxp), Enoby (denosumab-qbde), Bilprevda (denosumab-nxxp) and Xtrenbo (denosumab-qbde) now listed as preferred denosumab products.
• Boncresa, Bosaya, Conexxence, Jubbonti, Ospomyv, Osvyrti, Prolia, and Stoboclo now listed as non‑preferred products, and to require an inadequate response or intolerance to both Bildyos (denosumab‑nxxp) and Enoby (denosumab‑qbde).
• Aukelso, Bomyntra, Jubereq, Osenvelt, Oziltus, Wyost, Xbryk, and Xgeva now listed as non‑preferred products, and to require an inadequate response or intolerance to both Bilprevda (denosumab‑nxxp) and Xtrenbo (denosumab‑qbde).
• Criteria for prevention of skeletal‑related events in multiple myeloma and bone metastases from solid tumors to include a dose limit of 120 mg every 4 weeks.

Mobile Cardiac Outpatient Telemetry and Implantable Loop Recorders, 2.02.510  Individual | Group
Medical necessity criteria updated

• Now includes a requirement for implantable loop recorders (ILRs) that individuals must undergo monitoring for more the 14 consecutive days.
• Individuals may be eligible for ILRs when undergoing evaluation for suspected atrial fibrillation (AF) as a cause of cryptogenic stroke who have had a negative standard AF workup.

Effective July 2, 2026

Drugs for Rare Diseases, 5.01.576  Individual | Group
Medical necessity criteria added

• Givlaari (givosiran) is subject to review for site of service administration.

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

• Keytruda Qlex (pembrolizumab and berahyaluronidase alfa-pmph) SC is subject to review for site of service administration.

Immune Globulin Therapy, 8.01.503  Individual | Group
Medical necessity criteria added

• Yimmugo (immune globulin intravenous, human-dira) is subject to review for site of service administration.

Medical necessity criteria updated

• Guillain-Barre syndrome treatment criteria now requires severe disease with significant weakness and initiation of treatment within 4 weeks of symptom onset.
• Multifocal motor neuropathy criteria now requires stepwise or slowly progressive asymmetric limb weakness for at least 1 month, motor involvement of at least 2 nerves on nerve conduction studies, and normal sensory nerve conduction studies except for minor vibration loss in the lower limbs.
• Neuromyelitis optica spectrum disorder criteria now allows diagnosis confirmation based on a single clinical characteristic.
• Antiphospholipid syndrome criteria now allows catastrophic antiphospholipid syndrome when plasma exchange is not an option and intravenous immunoglobulin is not used as chronic or prophylactic therapy.

Pharmacologic Treatment of High Cholesterol, 5.01.558  Individual | Group
Medical necessity criteria added

• Leqvio (inclisiran) is subject to review for site of service administration.

Pharmacologic Treatment of Transthyretin-Mediated Amyloidosis, 5.01.593  Individual | Group
Medical necessity criteria added

• Amvuttra (vutrisiran) and Onpattro (patisiran) are subject to review for site of service administration.

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

• Rystiggo (rozanolixizumab-noli) is subject to review for site of service administration.

Medical necessity criteria updated

• Voyxact criteria revised to lower urine protein-to-creatinine ratio (UPCR) thresholds, add an estimated Glomerular Filtration Rate greater than or equal to 30 mL/min/1.73 m² requirement, exclude individuals on dialysis or post‑transplant, and require prior inadequate response or intolerance to Filspari or Tarpeyo.

Prostate Artery Embolization, 7.01.55  Individual | Group
New policy

• Prostate artery embolization is considered investigational as a treatment for benign prostatic hyperplasia.

Reconstructive Breast Surgery/Management of Breast Implants, 7.01.533  Individual | Group
Medical necessity criteria updated

• Poland syndrome added to the list of breast conditions for which reconstructive breast surgery may be considered medically necessary when criteria are met.

Site of Service: Infusion Drugs and Biologic Agents, 11.01.523  Individual | Group
New policy

• Amvuttra (vutrisiran), Onpattro (patisiran), Yimmugo (immune globulin), Givlaari (givosiran), Keytruda Qlex (pembrolizumab and berahyaluronidase alfa‑pmph), Leqvio (inclisiran), and Rystiggo (rozanolixizumab‑noli) are subject to review for site of service administration.

Effective July 1, 2026

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

• Updated from Site of Service Ambulatory Service Center Select Surgical Procedures to Site of Service Ambulatory Service Center Select Surgical or Diagnostic Procedures in Adults.

Medical necessity criteria added

• Upper Gastrointestinal Endoscopy is subject to review for site of service.

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

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

Medical necessity criteria added

• UGI endoscopy is subject to review for site of service.

Effective June 14, 2026

Effective for dates of service on and after June 14, 2026, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Genetic Testing. 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.

Chromosomal microarray analysis

• Expanded to allow fetal testing in any individual undergoing invasive diagnostic testing

Pharmacogenetic testing

• Expanded list of drug therapies and biomarkers considered medically necessary

Whole exome sequencing and whole genome sequencing

• Added criteria for which postnatal whole genome sequencing is considered medically necessary

Liquid biopsy testing

• Added allowance for repeat testing in breast cancer with disease progression when the patient is a candidate for specific new systemic therapies aligned with Food and Drug Administration or National Comprehensive Cancer Network 2A recommendations

Liquid biopsy, Whole Exome/Whole Genome, Predictive and Prognostic Polygenic Testing, Pharmacogenetic Testing, Chromosomal Microarray Analysis

• Added statement clarifying that testing should be performed in a lab certified by CLIA and accredited by the College of American Pathologists

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

Effective June 5, 2026

Carpal Tunnel Release Surgical Treatments, 7.01.595  Individual | Group
Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525  Individual | Group
Medical necessity criteria updated

• Carpal Tunnel Release Surgical Treatments are subject to review for site of service.

Intracoronary Drug Delivery Balloon Procedures, 7.01.97  Individual | Group
New policy

• The use of percutaneous coronary intervention with a drug-coated balloon for the treatment of intracoronary in-stent restenosis is considered investigational.

Effective for dates of service on and after June 5, 2026, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Radiation Therapy. 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.

Radiation Therapy Program Expansion

Addition of Electronic Brachytherapy – Skin and Orthovoltage

• Clinical indications:
  • Treatment of non‑melanoma skin cancers, including basal cell carcinoma and squamous cell carcinoma.
  • Use in select non‑malignant conditions.

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 June 1, 2026

Continuous Passive Motion in the Home Setting, 1.01.540  Individual | Group
Durable Medical Equipment, 1.01.529  Individual | Group
Medical necessity criteria added

• Use of devices or systems featuring continuous passive motion with remote monitoring or adaptive capabilities (i.e., ROMTech PortableConnect device) is considered investigational.

Contractual exclusion criteria removed

• ROMTech PortableConnect device moved from Durable Medical Equipment, 1.01.529 to Continuous Passive Motion in the Home Setting, 1.01.540.

Myoelectric Prosthetic and Orthotic Components for the Upper Limb, 1.04.502  Individual | Group

• A custom fitted powered glove with sensors and cables to support hand and finger movements with microprocessor, pressure sensors and components/accessories is considered investigational (e.g., Carbonhand).

Revised pharmacy policies
Effective June 1, 2026

Antipsychotics, 5.01.659  Individual | Group
Length of approval criteria updated

• Non-formulary exception review no longer included in authorization criteria.

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

• Fabhalta (iptacopan) criteria to reduce proteinuria in adults with complement 3 glomerulopathy and immunoglobulin A nephropathy moved from Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564 to this policy.

Length of approval criteria updated

• Non-formulary exception review no longer included in authorization criteria.
• Bkemv (eculizumab-aeeb), Empaveli (pegcetacoplan), Epysqli (eculizumab-aagh), Piasky (crovalimab-akkz), Syfovre (pegcetacoplan), Soliris (eculizumab), Tavneos (avacopan), Ultomiris (ravulizumab-cwvz) IV, and Veopoz (pozelimab-bbfg) initial approval length increased from 6 months to 12 months.

Medical Necessity Criteria for Custom Open Formulary, 5.01.647  Individual | Group
Medical necessity criteria updated

• Simlandi (adalimumab‑ryvk), adalimumab-ryvk, and adalimumab-adbm [NDCs starting with 82009] are now non-preferred products.
• Cosentyx (secukinumab) for the treatment of ankylosing spondylitis age requirement decreased from 18 to 12 years or older.
• Second line adalimumab products, Riabni (rituximab-arrx), Ruxience (rituximab-pvvr), Truxima (rituximab-abbs), Rituxan (rituximab), Rituxan Hycela (rituximab and hyaluronidase human), Actemra (tocilizumab), Avtozma (tocilizumab-anoh), Tofidence (tocilizumab-bavi), Tyenne (tocilizumab-aazg), Infliximab (Janssen – unbranded), Remicade (infliximab), Renflexis (infliximab-abda), Avsola (infliximab-axxq), Inflectra (infliximab-dyyb), Bimzelx (bimekizumab-bkzx), Cimzia (certolizumab pegol), Cosentyx (secukinumab), Entyvio (vedolizumab) SC, Kevzara (sarilumab), Kineret (anakinra), Ilumya (tildrakizumab-asmn), Olumiant (baricitinib), Orencia (abatacept), Siliq (brodalumab), Simponi (golimumab) SC, and Zeposia (ozanimod) now include adalimumab-aaty, adalimumab-adaz, and adalimumab-adbm [NDCs starting with 00597] as preferred alternatives.
• Bimzelx (bimekizumab-bkzx), Cimzia (certolizumab), Cosentyx (secukinumab), Orencia (abatacept), and Simponi (golimumab) SC treatment for psoriatic arthritis list of preferred alternatives now includes Sotyktu (deucravacitinib).
• Olumiant (baricitinib) criteria revised to include a quantity limit of 30 tablets per 30 days.

Medical necessity criteria removed

• Yuflyma (adalimumab-aaty) has been discontinued.

Miscellaneous Pharmacologic Treatments of Psoriasis, 5.01.652  Individual | Group
Medical necessity criteria removed

• Dovonex (calcipotriene) and Soriatane (acitretin) have been discontinued.

Medical necessity criteria updated

• Spevigo (spesolimab-sbzo) SC criteria to clarify that it is for the treatment of individuals with generalized pustular psoriasis (GPP) when not experiencing a flare, the individual weighs at least 40 kg, and has a history of at least 2 GPP flares of moderate-to-severe intensity.
• Spevigo (spesolimab-sbzo) IV criteria to clarify that the individual weighs at least 40 kg, and updated re-authorization criteria clarifying individual previously received Spevigo (spesolimab-sbzo) IV treatment for a prior GPP flare and achieved clinical response, and is now experiencing a new flare.

Length of approval criteria updated

• Non-formulary exception review no longer included in authorization criteria.

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

• Simlandi (adalimumab‑ryvk), adalimumab-ryvk, and adalimumab-adbm [NDCs starting with 82009] are now non-preferred products.
• Preferred alternatives to include adalimumab‑aaty, adalimumab‑adaz, and adalimumab‑adbm (NDCs starting with 00597).
• Ustekinumab-aauz now a non-preferred product.
• Bimzelx (bimekizumab-bkzx), Cimzia (certolizumab pegol), Cosentyx (secukinumab), Orencia (abatacept), and Simponi (golimumab) SC preferred alternatives now include adalimumab-aaty, adalimumab-adaz, adalimumab-adbm [NDCs starting with 00597], and Sotyktu (deucravacitinib).

Medical necessity criteria added

• Sotyktu (deucravacitinib) may be considered medically necessary for the treatment of active psoriatic arthritis when criteria are met.

Medical necessity criteria removed

• Yuflyma (adalimumab-aaty) has been discontinued.

Length of approval criteria updated

• Non-formulary exception review no longer included in authorization criteria.

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

• Simlandi (adalimumab‑ryvk), adalimumab-ryvk, and adalimumab-adbm [NDCs starting with 82009] are now non-preferred products.
• Preferred alternatives to include adalimumab‑aaty, adalimumab‑adaz, and adalimumab‑adbm (NDCs starting with 00597).
• Ustekinumab-aauz now a non-preferred product.
• Bimzelx (bimekizumab-bkzx), Cimzia (certolizumab pegol), Cosentyx (secukinumab), Ilumya (tildrakizumab-asmn), and Siliq (brodalumab) preferred alternatives now include adalimumab-aaty, adalimumab-adaz, and adalimumab-adbm [NDCs starting with 00597].

Medical necessity criteria removed

• Yuflyma (adalimumab-aaty) has been discontinued.

Length of approval criteria updated

• Non-formulary exception review no longer included in authorization criteria.

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

• Simlandi (adalimumab‑ryvk), adalimumab-ryvk, and adalimumab-adbm [NDCs starting with 82009] are now non-preferred products.
• Preferred alternatives for the treatment of ankylosing spondylitis, polyarticular juvenile idiopathic arthritis, and rheumatoid arthritis to include adalimumab‑aaty, adalimumab‑adaz, and adalimumab‑adbm (NDCs starting with 00597).
• Cosentyx (secukinumab) for the treatment of ankylosing spondylitis age requirement decreased from 18 to 12 years or older.
• Olumiant (baricitinib) criteria revised to include a quantity limit of 30 tablets per 30 days.

Medical necessity criteria removed

• Yuflyma (adalimumab-aaty) has been discontinued.

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

• Simlandi (adalimumab‑ryvk), adalimumab-ryvk, and adalimumab-adbm [NDCs starting with 82009] are now non-preferred products.
• Preferred alternatives to include adalimumab‑aaty, adalimumab‑adaz, and adalimumab‑adbm (NDCs starting with 00597).
• Ustekinumab-aauz now included as a non-preferred product.
• Cimzia (certolizumab pegol), Entyvio (vedolizumab) SC, Simponi (golimumab) SC, and Zeposia (ozanimod) criteria now include adalimumab-aaty, adalimumab-adaz, and adalimumab-adbm [NDCs starting with 00597] as preferred alternatives.
• Yesintek (ustekinumab-kfce), Steqeyma (ustekinumab-stba), Stelara (ustekinumab), Imuldosa (ustekinumab-srlf), Otulfi (ustekinumab-aauz), Pyzchiva (ustekinumab-ttwe), Selarsdi (ustekinumab-ackn), Starjemza (ustekinumab-hmny), ustekinumab, ustekinumab-aekn, ustekinumab-ttwe, and Wezlana (ustekinumab-auub) criteria for the treatment of Crohn's disease decreased age requirement from 18 years to 2 years or older.

Medical necessity criteria removed

• Yuflyma (adalimumab-aaty) has been discontinued.

Length of approval criteria updated

• Non-formulary exception review no longer included in authorization criteria.

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

• Simlandi (adalimumab‑ryvk), adalimumab-ryvk, and adalimumab-adbm [NDCs starting with 82009] are now non-preferred products.
• Preferred alternatives to include adalimumab‑aaty, adalimumab‑adaz, and adalimumab‑adbm (NDCs starting with 00597).
• Cosentyx (secukinumab) for the treatment of hidradenitis suppurativa age requirement decreased from 18 years to 12 years or older.

Medical necessity criteria removed

• Yuflyma (adalimumab-aaty) has been discontinued.
• Fabhalta (iptacopan) criteria to reduce proteinuria in adults with complement 3 glomerulopathy and immunoglobulin A nephropathy moved from this policy to C3 and C5 Complement Inhibitors, 5.01.571.

Length of approval criteria updated

• Non-formulary exception review no longer included in authorization criteria.

Pharmacotherapy of Multiple Sclerosis, 5.01.565  Individual | Group
Length of approval criteria updated

• Non-formulary exception review no longer included in authorization criteria.

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

• Preferred alternatives for rheumatoid arthritis to include adalimumab‑aaty, adalimumab‑adaz, and adalimumab‑adbm (NDCs starting with 00597).

Length of approval criteria updated

• Non-formulary exception review no longer included in authorization criteria.

SGLT2 Inhibitors, 5.01.646  Individual | Group
Medical necessity criteria updated

• Bexagliflozin, Brenzavvy (bexagliflozin), brand dapagliflozin-metformin, Invokana (canagliflozin), Invokamet (canagliflozin-metformin), Invokamet XR (canagliflozin-metformin extended-release), Steglatro (ertugliflozin), and Segluromet (ertugliflozin-metformin) preferred alternatives no longer includes Farxiga (dapagliflozin) and Xigduo XR, and now includes dapagliflozin and dapagliflozin-metformin XR.

Medical necessity criteria removed

• Brand dapagliflozin, brand dapagliflozin-metformin, Farxiga (dapagliflozin) and Xigduo XR (dapagliflozin-metformin extended-release) no longer included in policy.

No updates this month.

No updates this month.

Added codes
Effective September 4, 2026

Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence, 1.01.17  Individual | Group
Now considered investigational.

E0740

Added codes
Effective July 2, 2026

Prostate Artery Embolization, 7.01.55  Individual | Group
Now requires review for medical necessity and prior authorization.

37243

Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions, 2.01.543  Individual | Group
Now considered investigational.

G0465

Reconstructive Breast Surgery/Management of Breast Implants, 7.01.533  Individual | Group
Now requires review for cosmetic and prior authorization.

15769

Now requires review for cosmetic.

C1789

Effective June 5, 2026

Carelon Medical Benefits Management Radiation Oncology
Now reviewed by Carelon for medical necessity and prior authorization.

70472

Intracoronary Drug Delivery Balloon Procedures, 7.01.97  Individual | Group
Now considered investigational.

0913T, 0914T, C9610

Revised codes
Effective July 2, 2026

Drugs for Rare Diseases, 5.01.576  Individual | Group
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J0223

Immune Checkpoint Inhibitors, 5.01.591  Individual | Group
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J9277

Immune Globulin Therapy, 8.01.503  Individual | Group
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J1553

Pharmacologic Treatment of High Cholesterol, 5.01.558  Individual | Group
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J1306

Pharmacologic Treatment of Transthyretin-Mediated Amyloidosis, 5.01.593  Individual | Group
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J0225

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  Individual | Group
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

J9333

Site of Service: Infusion 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.

J0223, J0225, J1306, J1553, J9277, J9333

Effective July 1, 2026

Site of Service Ambulatory Service Center (ASC): Select Surgical Procedures for Adults, 11.01.525  Individual | Group
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 June 5, 2026

Carelon Medical Benefits Management Radiation Oncology
Now reviewed by Carelon for medical necessity and prior authorization.

77436, 77437, 77438, 77439

Carpal Tunnel Release Surgical Techniques, 7.01.595  Individual | Group
Site of Service Ambulatory Service Center (ASC) Select Surgical or Diagnostic Procedures in Adults, 11.01.525  Individual | Group
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

29848, 64721

Removed codes
Effective June 5, 2026

Electronic Brachytherapy for Nonmelanoma Skin Cancer, 8.01.62  Individual | Group
Now reviewed by Carelon for medical necessity and prior authorization.

77436, 77437, 77438, 77439

Effective June 1, 2026

Occipital Nerve Stimulation, 7.01.125  Individual | Group
No longer requires review.

L8684

Shoulder Arthrotomy in Adults, 7.01.605  Individual | Group
Now reviewed by Carelon for medical necessity and prior authorization.

20680, 20670, 23040, 23044, 23101, 23107, 23415, 23585, 23615, 23616, 23630

Effective June 1, 2026

Testosterone, 15.01.017  Individual | Group
Medical necessity criteria updated

• Correction to measurement of serum free and/or bioavailable testosterone to indicate that testing as a primary test, and for asymptomatic individuals or those with nonspecific symptoms is not reimbursable. These statements were previously listed as reimbursable in error.

No updates this month.

No updates this month.

No updates this month.