Medical Policy and Coding Updates

Effective February 5, 2027

Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis, 7.01.610  Individual | Group
New policy

• This policy replaces Policy 7.01.168 Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis.
• Resection (neurectomy) of the posterior nasal nerve for chronic rhinitis is considered investigational (aka the selective postganglionic pterygopalatine parasympathectomy [SP3] procedure).

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

• Keytruda Qlex criteria now require the individual to receive Keytruda (pembrolizumab) IV.
• Opdivo Qvantig criteria now require the individual to receive Opdivo (nivolumab) IV.
• Tecentriq Hybreza criteria now require the individual to receive Tecentriq (atezolizumab) IV.

Mammography-based AI (Image-only) Risk Prediction Models for Breast Cancer, 6.01.31  Individual | Group
New policy

• Mammography-based AI risk prediction software is considered investigational for individuals undergoing bilateral screening mammography to determine candidacy for the increased-risk management pathway.

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

• Elzonris (tagraxofusp-erzs) criteria now include Decnupaz in the list of medications that should not be used concurrently and require prescribing by an appropriate specialist.

Medical necessity criteria added

• Decnupaz (pivekimab sunirine-pvzy) may be considered medically necessary for the treatment of blastic plasmacytoid dendritic cell neoplasm when criteria are met.

Mohs Micrographic Surgery, 7.01.608  Individual | Group
New policy

• Mohs micrographic surgery is considered medically necessary when criteria are met.

Navigated Repetitive Transcranial Magnetic Stimulation for Presurgical Mapping, 2.01.109  Individual | Group
New policy

• Navigated repetitive transcranial magnetic stimulation (nTMS) of the brain using an FDA-cleared device and modality is considered investigational for preoperative motor or language mapping in individuals undergoing surgery for brain tumors or other intracranial lesions near eloquent cortex.

Optilume Device for Urethral Stricture and Benign Prostatic Hyperplasia, 7.01.183  Individual | Group
New policy

• The Optilume urethral drug-coated balloon may be considered medically necessary for the treatment of recurrent anterior (bulbar) urethral stricture in adult men when criteria are met.
• The Optilume urethral drug-coated balloon is considered investigational for the treatment of anterior urethral stricture in all other circumstances.
• The Optilume Benign Prostatic Hyperplasia Catheter System is considered investigational for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia.

Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation, 2.02.519  Individual | Group
Policy renumbered

• This policy replaces Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation, 2.02.26.

Medical necessity criteria updated

• Criteria now include non-valvular atrial fibrillation; elevated annual risk of stroke based on a CHA₂DS₂-VASc score greater than or equal to 2 in males or greater than or equal to 3 in females; candidacy for long-term anticoagulation therapy based upon estimated risk of stroke and other systemic thromboembolic events; contraindication to long term oral anticoagulation (OAC) due to a nonreversible cause; and high risk of major bleeding on long-term OAC with HAS-BLED score greater than or equal to 3.

Pharmacologic Treatment of Urea Cycle Disorders, 5.01.611  Individual | Group
Medical necessity criteria added

• Loargys (pegzilarginase-nbln) may be considered medically necessary for the treatment of hyperargininemia when criteria are met.

Medical necessity criteria removed

• Removed reference to non-formulary exception review.

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

• Added Cligavyx (fulvestrant) to the policy with the same criteria as Faslodex (fulvestrant).

Effective January 1, 2027

HER2 Inhibitors, 5.01.514  Individual | Group
Medical necessity criteria updated

• Kanjinti (trastuzumab-anns) is now a non-preferred trastuzumab product.

High-Risk Conditions (Oral Health) Benefit, 10.01.535  Individual | Group
Title changed

• Title changed from High-Risk Conditions (Oral Health) to Enhanced Dental Care.

Medical necessity criteria updated

• Periodontal services are now covered for individuals with conditions recognized by the Centers for Disease Control as impacting oral health.

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

• Updated Truxima (rituximab-abbs) from a preferred product to a non-preferred product.
• Updated non-preferred rituximab products, Rituxan and Rituxan Hycela, removing Truxima from list of preferred rituximab products.
• Updated criteria for all non-preferred agents removing Stelara (ustekinumab) as a preferred alternative for treatment of Crohn's disease, plaque psoriasis, psoriatic arthritis, and ulcerative colitis.

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

• Truxima (rituximab-abbs) is now a non-preferred rituximab product.

Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease, 7.01.594  Individual | Group
Investigational criteria added

• Endovenous femoropopliteal bypass using a stent graft (DETOUR procedure) for individuals with lower extremity peripheral artery disease is considered investigational in all situations.

Medical necessity criteria updated

• Criteria now specify documented discussion of the importance of smoking cessation and/or implementation of a plan to begin smoking cessation, if applicable.

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

• Stelara (ustekinumab) is now a non-preferred product and has been removed as a preferred alternative for all non-preferred agents.

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

• Stelara (ustekinumab) is now a non-preferred product and has been removed as a preferred alternative for all non-preferred agents.

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

• Stelara (ustekinumab) is now a non-preferred product and has been removed as a preferred alternative for all non-preferred agents.

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

• Truxima (rituximab-abbs) is now a non-preferred rituximab product.

Site of Service Ambulatory Surgery Center (ASC): Procedures Not Subject to Medical Necessity Review, 11.01.526  Individual | Group
New policy

• Procedures performed in the ASC setting may be considered medically necessary without review; all other sites of care may be considered medically necessary when criteria are met.

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

• Alymsys, Avastin, Avzivi, and Jobevne criteria now require a trial of all preferred bevacizumab products.

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

• Eylea (aflibercept) criteria for the treatment of retinopathy of prematurity (ROP) now require a trial of Pavblu (aflibercept-ayyh).

Effective December 3, 2026

Knee Arthroscopy in Adults, 7.01.549  Individual | Group
Medical necessity criteria added

• Knee arthroscopy for a synovectomy (limited procedure) may be considered medically necessary when criteria are met.

Medical necessity criteria updated

• Under the intra-articular joint pathology indication, symptoms of pathological plica must not have responded to conservative care measures.

Medical necessity criteria removed

• Diagnostic imaging is no longer required within 12 months prior to the requested surgery.

Pharmacotherapy of Spinal Muscular Atrophy (SMA), 5.01.574  Individual | Group
Medical necessity criteria updated

• Itvisma (onasemnogene abeparvovec brve) and Zolgensma (onasemnogene abeparvovec xioi) criteria now define the clinical characteristics that constitute advanced SMA, replacing the previous exclusion criterion that the individual does not have advanced SMA.

Effective November 15, 2026

Effective for dates of service on and after November 15, 2026, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Radiation Oncology. 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 Oncology

• Established a new guideline for radiation therapy in select non-malignant conditions, including vascular, inflammatory, fibrotic, and neurologic disorders.
• Added criteria specifying that radiation therapy is considered not medically necessary for select conditions, including osteoarthritis, neovascular age-related macular degeneration, and refractory ventricular tachycardia.

Effective for dates of service on and after November 15, 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.

Multiple guidelines (Genetic Liquid Biopsy and Somatic Tumor Testing)

• General Criteria
  • Revised criteria to require demonstration of clinical utility for all test components.

Genetic Liquid Biopsy in the Management of Cancer and Cancer Surveillance

• General Information
  • Defined circulating tumor-tissue-modified viral HPV DNA (ctHPV DNA).
• General Criteria for Genetic Liquid Biopsy Testing
  • Added criteria specifying that RNA fusion, expression, and whole transcriptome analysis using ctRNA are not medically necessary.
  • Clarified that reflex tissue biopsy is permitted following liquid biopsy when no actionable variant is detected or results are uninformative.
• Breast Carcinoma
  • Expanded coverage criteria to include recurrent and locally advanced breast cancer, including American Journal if Critical Care stage IIB, IIIA, IIIB, and IIIC disease, in addition to metastatic disease.
  • Added imlunestrant to the list of therapies for which ESR1 mutation testing is considered medically necessary.
• Prostate Carcinoma
  • Expanded the list of therapies for which testing is considered medically necessary to include niraparib.
• ctDNA for Molecular Residual Disease (MRD) or Therapy Response
  • Clarified the use of ctDNA to assess therapy response, specified common indications for which MRD testing is considered not medically necessary, and added test examples.
• ctHPV DNA Testing for Recurrence, Surveillance, Post-Treatment Molecular Residual Disease or Therapy Response
  • Revised criteria to state that ctHPV DNA testing in oropharyngeal carcinoma is considered not medically necessary.
• Individuals without Malignancy for whom Liquid Biopsy is Used for Screening
  • Expanded the list of test examples to include CancerGuard.

Somatic Tumor Testing (Solid Tumors)

• General Criteria
  • Revised criteria to require demonstration of clinical utility for all test components.
  • Expanded coverage criteria to permit targeted RNA-based fusion analysis using next-generation sequencing when specified in the applicable cancer-specific criteria.
  • Added an exception permitting reflex tissue biopsy following liquid biopsy when no actionable variant is detected or results are uninformative.
• Tissue-agnostic Testing for Patients with Advanced Solid Tumors
  • Expanded coverage criteria to permit HER2 testing.
  • Removed criteria related to FGFR1/2/3 fusions and pathogenic or likely pathogenic (P/LP) variants.
• Biliary Tract Cancer (including Cholangiocarcinoma and Gallbladder Cancer)
  • Clarified that comprehensive molecular testing must include the genes specified in the criteria.
• Bladder Cancer (Urothelial Carcinoma, including the Upper Tract)
  • Expanded eligibility to include individuals with unresectable or metastatic bladder cancer at initial diagnosis.
• Brain Cancer (Malignant Glioma)
  • Expanded testing criteria to include pathogenic and likely pathogenic (P/LP) H3 K27M variants following FDA approval of doranidazole (Modeyso) for individuals with diffuse midline glioma.
  • Expanded testing criteria to include BRAF fusions and rearrangements following FDA approval of tovorafenib (Ojemda) for individuals with pediatric low-grade glioma.
  • Added criteria for use of MGMT promoter methylation testing.
• Breast Cancer, localized invasive, early adjuvant setting (split criteria by lymph node status)
  • Expanded eligibility for Oncotype DX testing to include premenopausal individuals or those younger than age 50 with lymph node-negative, omitted, or micrometastatic disease.
  • Clarified testing eligibility for postmenopausal individuals or those age 50 and older with lymph node-negative, omitted, or micrometastatic disease.
  • Expanded testing criteria to include EndoPredict for individuals with 1 to 3 positive axillary lymph nodes.
  • Expanded testing eligibility for individuals older than age 50 with axillary lymph node-positive disease and incorporated clinical nodal status into pathologic nodal status criteria.
  • Added criteria specifying that testing in breast cancer recurrence is considered not medically necessary.
• Breast Cancer, localized; extended adjuvant setting
  • Clarified that testing for breast cancer recurrence is considered not medically necessary.
• Breast Cancer, metastatic and/or locally advanced
  • Revised criteria to include imlunestrant among therapies eligible for molecular testing.
• Colorectal Cancer, localized
  • Added PIK3CA testing as a predictive biomarker.
• Colorectal Cancer, metastatic
  • Expanded extended RAS testing criteria to include the KRAS p.G12C variant for therapy selection.
• Non-small Cell Lung Cancer, advanced (stage IIIB, IIIC, or IV metastatic)
  • Expanded indications for rebiopsy following disease progression on targeted therapies, including therapies directed at ALK, ROS1, RET, MET, BRAF, HER2, KRAS G12C, and NTRK alterations.
• Ovarian (Epithelial) Cancer
  • Expanded the scope of the criteria to include fallopian tube and primary peritoneal cancers.
  • Added a maintenance therapy indication for homologous recombination deficiency testing.
• Pancreatic Adenocarcinoma
  • Removed stage-specific requirements for testing.
• Prostate Cancer, metastatic
  • Expanded criteria from metastatic adenocarcinoma to metastatic prostate cancer.
  • Expanded testing eligibility to all metastatic prostate cancer indications by removing the requirement for metastatic castrate-sensitive adenocarcinoma with high-volume disease.
  • Expanded the list of poly ADP ribose polymerase inhibitor therapies to include niraparib and talazoparib.
  • Expanded multigene panel testing criteria to include additional genes.
• Sarcoma (including soft tissue sarcoma, bone sarcoma, gastrointestinal stromal tumor, uterine sarcoma)
  • Expanded indications for resistance mutation testing in the setting of clinical progression on targeted therapy.
• Thyroid Neoplasm, noninvasive follicular with papillary-like nuclear features (NIFTP)
  • Clarified that somatic testing of NIFTP is considered not medically necessary.
• Thyroid Cancer, recurrent or persistent locoregional medullary cancer
  • Added criteria supporting testing in medullary thyroid cancer.
• Thyroid Cancer, metastatic, locally advanced, recurrent, progressive, symptomatic
  • Added positive coverage criteria for testing in locally advanced, recurrent, progressive, and symptomatic thyroid cancer.
  • Removed restrictions on the number of genes included in testing.
  • Expanded testing criteria to include additional genes and tumor mutational burden (TMB) testing.
• Thyroid Cancer, anaplastic thyroid cancer
  • Expanded testing criteria to include additional genes and TMB testing that may be considered in clinical decision making.
• Unknown Primary Site Cancer
  • Added positive coverage criteria for microsatellite instability testing in cancers of unknown primary origin.
  • Added positive coverage criteria for multigene panel testing in cancers of unknown primary origin.
  • Added a list of genes recommended for testing.
• Whole Exome (WES), Whole Genome (WGS), and Whole Transcriptome Analysis (WTA)
  • Added criteria specifying that WES, WGS, and WTA are considered not medically necessary.

Hematologic Malignancies

• Tissue, Bone Marrow, or Blood-Agnostic Testing for Patients with Hematological Cancers
  • Added criteria permitting targeted RNA fusion analysis when specified in the applicable cancer-specific criteria.
• Acute Lymphoblastic Leukemia and Pediatric B-cell Precursor Lymphoblastic Lymphoma
  • Established gene-specific criteria for multigene panels containing 50 or fewer genes.
• B-cell Lymphomas
  • Expanded testing criteria to permit testing on lymph node tissue.
  • Expanded testing indications to include risk stratification and identification of actionable therapeutic targets.
• Chronic Lymphocytic Leukemia
  • Added a requirement that multigene panels include testing of the TP53 gene.
• Myeloproliferative Neoplasms
  • Expanded molecular testing criteria to include select non-hematologic abnormalities in the absence of hematologic abnormalities, including unexplained splanchnic, cerebral, or arterial thrombosis.
• Myelodysplastic Syndrome
  • Broadened multigene panel testing criteria to include additional gene targets.
• Multiple Myeloma
  • Added positive coverage criteria for NGS and molecular testing in multiple myeloma.
  • Added criteria specifying when NGS and molecular testing are not indicated in multiple myeloma.
• Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma
  • Added positive coverage criteria for molecular testing in Waldenström macroglobulinemia/lymphoplasmacytic lymphoma.
  • Clarified that gene expression testing is 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 November 16, 2026

Psychiatric and Other Specified Evaluations in Inpatient and Residential Behavioral Health Treatment, 3.01.521  Individual | Group
Title changed

• Title changed from Psychiatric and Other Specified Evaluations in Inpatient and Residential Behavioral Health Treatment to Psychiatric and Other Specified Evaluations in Inpatient, Residential, and Partial Hospital Program Behavioral Health Treatment

Medical necessity criteria updated

• Changed the term “detoxification” to “withdrawal management (detoxification)” to align with InterQual and American Society of Addiction Medicine terminology, as well as preferred language within the substance use disorder professional community.
• Initial psychiatric evaluation for residential mental health treatment, including residential eating disorder treatment, may be completed within two calendar days after admission.
• Subsequent psychiatric evaluations are required at least once every 10 days during residential and partial hospital program (PHP) mental health and eating disorder treatment.
• Subsequent nutritional assessments by a registered dietician are required once every week during residential eating disorder treatment.
• Nutritional assessments are required at least once every 10 days during PHP eating disorder treatment.
• Substance use evaluations are required at least once every 10 days during PHP substance use disorder treatment.
• Removed nursing assessment and observation requirements for hospital inpatient levels of care, as hospitals are required to maintain 24/7 nursing services for legal operation, Medicare and Medicaid participation, and accreditation.

Medical necessity criteria added

• InterQual Criteria added for psychiatric, substance use, and nutritional evaluations during applicable PHP treatment.
• Specified the clinician types authorized to perform each evaluation, consistent with the clinician requirements for the same evaluations in residential treatment settings.

Effective November 6, 2026

Endovascular Stent Grafts for Abdominal Aortic Aneurysms, 7.01.601  Individual | Group
Medical necessity criteria added

• Endovascular aneurysm repair (EVAR) of infra-renal abdominal aortic or aorto-iliac aneurysms using endoprostheses may be considered medically necessary when criteria are met.
• EVAR criteria no longer require an aneurysmal diameter that measures twice the size of the normal infrarenal aorta.

Investigational criteria added

• Bifurcated-bifurcated endoprosthesis repair of aorto-iliac aneurysms for the treatment of abdominal aortic aneurysm is considered investigational.

Evaluation of Biomarkers for Alzheimer Disease, 2.04.521  Individual | Group
Title Change

• Title changed from Evaluation of Biomarkers for Alzheimer Disease to Evaluation of Cerebrospinal Fluid, Urine, and Plasma Tests for Alzheimer Disease.

Medical necessity criteria updated

• Cerebrospinal fluid biomarker tests which may be considered medically necessary are now specifically listed in criteria.

Investigational criteria updated

• Plasma testing of amyloid beta peptides and tau protein using tests that confirm amyloid pathology as part of an evaluation for the initiation of amyloid beta targeting therapy in individuals with mild cognitive impairment or mild dementia due to Alzheimer disease is considered investigational.

Immune Globulin Therapy, 8.01.503  Individual | Group
Site of Service: Infusion Drugs and Biologic Agents, 11.01.523  Individual | Group
Medical necessity criteria updated

• Qivigy (immune globulin) now requires site of service review.

Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome, 2.01.106  Individual | Group
Title Change

• Title changed from Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome to Percutaneous Electrical Nerve Field Stimulation for Disorders of Gut-Brain Interaction.

Investigational criteria updated

• Investigational criteria expanded to include abdominal pain-related disorders of gut-brain interaction, including irritable bowel syndrome and functional dyspepsia.

Synthetic Cartilage Implants for Joint Pain, 7.01.160  Individual | Group
Title Change

• Title changed from Synthetic Cartilage Implants for Joint Pain to Cartilage Implants for Joint Pain.

Medical necessity criteria updated

• Investigational criteria expanded to include cartilage implants in addition to synthetic cartilage.

New medical policies
Effective November 1, 2026

Prescription Digital Therapeutics for Substance Use Disorders, 5.01.643  Individual | Group
Policy renumbered

• This policy replaces Prescription Digital Therapeutics for Substance Use Disorders, 3.03.501.

Revised medical policies
Effective November 1, 2026

Deep Brain Stimulation, 7.01.609  Individual | Group
Medical necessity criteria updated

• Obsessive-compulsive disorder (OCD) for deep brain stimulation criteria now allow either failure of two selective serotonin reuptake inhibitors (SSRIs) plus failure of risperidone or aripiprazole as augmentation to at least one failed SSRI, or failure of clomipramine and one SSRI plus failure of risperidone or aripiprazole as augmentation to the failed SSRI.

Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain and Other Conditions, 7.01.574  Individual | Group
Investigational criteria updated

• Peripheral nerve stimulation for the management of chronic pain is considered investigational for all indications.
• Implantable tibial nerve stimulation delivered by an implantable peripheral neurostimulator system is considered investigational for all indications.

Panniculectomy and Excision of Redundant Skin, 7.01.523  Individual | Group
Medical necessity criteria updated

• Panniculectomy criteria now clarify that the individual must have maintained a stable weight for at least 6 months prior to surgery, defined as no loss or gain exceeding 5% of body weight.

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

• For major depressive disorder, bipolar depression, and OCD, medication trial requirements which specify that each failed medication must be individually identified, and the reason or reasons for failure must be documented either for each medication individually or collectively for all failed medications, have been moved from the Additional Information section to the sections for each disorder.
• For OCD, transcranial magnetic stimulation (TMS) criteria now also allow either failure of two SSRIs plus failure of risperidone or aripiprazole as augmentation to at least one failed SSRI, or failure of clomipramine and one SSRI plus failure of risperidone or aripiprazole as augmentation to the failed SSRI.
• A repeat full intensive course of TMS may be considered medically necessary when a previous course of TMS failed if performed with a different protocol.

Upper Gastrointestinal (UGI) Endoscopy in Adults, 2.01.533  Individual | Group
Medical necessity criteria updated

• Barrett esophagus screening criteria modified to now require 5 years or more of GERD symptoms and at least 3 of the following risk factors: age 50 years or older, BMI greater than or equal to 30 kg/m², family history of Barrett esophagus or esophageal adenocarcinoma in a first-degree relative, male sex, tobacco use, or white race.

New pharmacy policies
Effective November 1, 2026

Peginterferon alfa, 5.01.664  Individual | Group
New policy

• Pegasys (peginterferon alfa-2a) coverage criteria moved to this policy from Chronic Hepatitis B and D Antiviral Therapy, 5.01.636.
• Pegasys (peginterferon alfa-2a) coverage criteria moved to this policy from Hepatitis C Antiviral Therapy, 5.01.606.

Revised pharmacy policies
Effective November 1, 2026

Bispecific Antibodies, 5.01.650  Individual | Group
Medical necessity criteria added

• Ziihera (zanidatamab-hrii) may be considered medically necessary for the treatment of unresectable locally advanced or metastatic gastric, gastroesophageal junction, or esophageal adenocarcinoma when criteria are met.

Chronic Hepatitis B Antiviral Therapy, 5.01.636  Individual | Group
Title Change

• Title changed from Chronic Hepatitis B Antiviral Therapy to Chronic Hepatitis B and D Antiviral Therapy.

Medical necessity criteria moved

• Pegasys (peginterferon alfa-2a) coverage criteria moved to Peginterferon alfa-2a, 5.01.664.

Medical necessity criteria added

• Hepcludex (bulevirtide-gmod) may be considered medically necessary for the treatment of chronic hepatitis D virus (HDV) infection with a current positive HDV RNA test when criteria are met.

Epidermal Growth Factor Receptor (EGFR) Inhibitors, 5.01.603  Individual | Group
Medical necessity criteria updated

• Erbitux (cetuximab) to remove the indication in combination with Krazati (adagrasib) for adults with KRAS G12C-mutated locally advanced or metastatic colorectal cancer.

Hepatitis C Antiviral Therapy, 5.01.606  Individual | Group
Medical necessity criteria removed

• Pegasys (peginterferon alfa-2a) coverage criteria moved to Peginterferon alfa-2a, 5.01.664.
• Pegintron (peginterferon alfa-2b) has been discontinued.
• Removed reference to non-formulary exception reviews.

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

• Tevimbra (tislelizumab-jsgr) may be considered medically necessary for the treatment of HER2 positive (IHC 3+ or ISH+) unresectable locally advanced or metastatic gastric, gastroesophageal junction, or esophageal adenocarcinoma when criteria are met.

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

• Quantity limits removed for Gavreto, Inrebic, Jakafi, Jakafi XR, Komzifti, Lifyorli, Lumakras, Lynparza, Modeyso, Ogsiveo, Ojjaar, Pemazyre, Revuforj, Romvimza, Voranigo, and Welireg; quantity limits are addressed in policy 5.01.656 Drug Quantity Management.
• Zepzelca (lurbinectedin) criteria for metastatic small cell lung cancer removed.
• Tazverik (tazemetostat) criteria removed as the product has been withdrawn from the market.
• Krazati (adagrasib) criteria for the treatment of KRAS G12-mutated locally advanced or metastatic colorectal cancer removed.

Medical necessity criteria updated

• Verzenio (abemaciclib) criteria expanded to include use in combination with imlunestrant for the treatment of adults with estrogen receptor-positive, HER2-negative, estrogen receptor-1-mutated advanced or metastatic breast cancer.
• Gazyva (obinutuzumab) criteria expanded to include use in combination with venetoclax for chronic lymphocytic leukemia.
• Temodar (temozolomide) and generic temozolomide criteria for anaplastic astrocytoma now specify use as first-line therapy rather than newly diagnosed disease and no longer require disease progression on nitrosourea and procarbazine regimens for refractory disease.

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

• Removed coverage criteria for generic icosapent ethyl.

Medical necessity criteria updated

• Leqvio, Nexletol, Nexlizet, and Repatha, atherosclerotic cardiovascular disease criteria now specify use to reduce the risk of major adverse cardiovascular events in adults at increased risk, and the low-density lipoprotein cholesterol (LDL-C) threshold was lowered from 70 mg/dL to 55 mg/dL.
• Leqvio, Lerochol, Nexletol, Nexlizet, Praluent, and Repatha, hypercholesterolemia criteria now require a LDL-C threshold of 70 mg/dL instead of 100 mg/dL.

Medical necessity criteria updated

• Tryngolza may be considered medically necessary to reduce triglycerides and the risk of acute pancreatitis in adult individuals with severe hypertriglyceridemia when criteria are met.

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

• Veppanu (vepdegestrant) 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 updated

• Inluriyo (imlunestrant) criteria now require use as monotherapy or in combination with abemaciclib.

Medical necessity criteria removed

• Quantity limits for Fareston (toremifene), Inluriyo (imlunestrant) and Orserdu (elacestrant) removed as quantity limits are addressed in policy 5.01.656 Drug Quantity Management.

Venclexta (venetoclax) BCL-2 Inhibitor, 5.01.568  Individual | Group
Title change

• Title changed from Venclexta (venetoclax) BCL-2 Inhibitor to BCL-2 Inhibitors.

Medical necessity criteria added

• Beqalzi (sonrotoclax) may be considered medically necessary for the treatment of relapsed or refractory mantle cell lymphoma when criteria are met.

Medical necessity criteria updated

• Venclexta (venetoclax) criteria for newly diagnosed acute myeloid leukemia now include Inqovi (decitabine and cedazuridine) in the list of medications it may be used in combination with.

Medical necessity criteria removed

• Removed reference to non-formulary exception reviews.

No updates this month.

Effective November 1, 2026

Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis, 7.01.168

• This policy is replaced with Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis, 7.01.610.

Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation, 2.02.26

• This policy is replaced with Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation, 2.02.519.

Prescription Digital Therapeutics for Substance Use Disorder, 5.01.643

• This policy is replaced with Prescription Digital Therapeutics for Substance Use Disorders, 3.03.501.

Added codes
Effective February 5, 2027

Carelon Management Radiology
Now requires review for medical necessity and prior authorization.

C9762, C9763

Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis, 7.01.610  Individual | Group
Now considered investigational.

30117, 31242, 31243

Mohs Micrographic Surgery, 7.01.608  Individual | Group
Now requires review for medical necessity and prior authorization.

17313, 17314, 17315

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

S3600, S3601

Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation, 2.02.519  Individual | Group
Now requires review for medical necessity and prior authorization.

33340

Pharmacologic Treatment of Urea Cycle Disorders, 5.01.611  Individual | Group
Now requires review for medical necessity and prior authorization.

J1818

Selective Estrogen Receptor Modulators and Down Regulators, 5.01.618  Individual | Group
Now requires review for medical necessity and prior authorization.

J9999

Sinus Surgery in Adults, 7.01.559  Individual | Group
Now requires review for medical necessity, including site of service review, and prior authorization.

31240

Urethral Drug-Coated Balloon for Urethral Stricture and Benign Prostatic Hyperplasia, 7.01.183  Individual | Group
Now requires review for medical necessity.

52284

Now considered investigational.

52443

Effective January 1, 2027

Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease, 7.01.594  Individual | Group
Now considered investigational.

C1604

Effective November 6, 2026

Immune Globulin Therapy, 8.01.503  Individual | Group
Site of Service: Drugs and Biologic Agents, 11.01.523  Individual | Group
Now requires site of service review. Review for medical necessity and prior authorization are still required.

J1577

Effective November 1, 2026

Digital Health Technologies: Eye-Tracking Diagnostic Device for Autism Spectrum Disorder, 3.03.08  Individual | Group
Now requires review for medical necessity.

E1399

Now considered investigational.

G0552, G0553, G0554

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

64598, C1778

Removed codes
Effective November 6, 2026

Synthetic Cartilage Implants for Joint Pain, 7.01.160  Individual | Group
No longer requires review.

28291

Effective November 1, 2026

Hepatitis C Antiviral Therapy, 5.01.606  Individual | Group
Chronic Hepatitis B Antiviral Therapy, 5.01.636  Individual | Group
No longer requires review for medical necessity.

S0145

Immune Checkpoint Inhibitors, 5.01.591  Individual | Group
No longer requires review for medical necessity.

J3590

Shoulder Open Procedures, 7.01.605  Individual | Group
No longer requires review for medical necessity.

23106, 23550, 23552

Revised codes
Effective December 3, 2026

Pharmacotherapy of Spinal Muscular Atrophy (SMA), 5.01.574  Individual | Group
No longer requires review for prior authorization. Review for medical necessity is still required.

J3399, J3405

Effective November 6, 2026

Endovascular Stent Grafts for Abdominal Aortic Aneurysms, 7.01.601  Individual | Group
Now considered investigational.

34717, 34718

No updates this month.

No updates this month.

Effective January 1, 2027

Routine Test Management Policies
New policies

• These policies are intended to support claims editing for laboratory services, with no 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 (e.g., diagnosis matching, frequency limits), not complex clinical decisions

Allergen Testing, 15.01.001  Individual
Biomarker Testing for Autoimmune Rheumatic Disease, 15.01.040  Individual
Biomarkers for Myocardial Infarction and Chronic Heart Failure, 15.01.034  Individual
Bone Turnover Markers Testing, 15.01.011  Individual
Celiac Disease Testing, 15.01.031 Individual
Coronavirus Testing in the Outpatient Setting, 15.01.014  Individual
Diagnosis of Idiopathic Environmental Intolerance, 15.01.036  Individual
Diagnostic Testing of Influenza, 15.01.018  Individual
Diagnostic Testing of Iron Homeostasis & Metabolism, 15.01.030  Individual
Epithelial Cell Cytology in Breast Cancer Risk Assessment, 15.01.033  Individual
Evaluation of Dry Eyes, 15.01.007  Individual
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing, 15.01.039  Individual
Fecal Calprotectin Testing in Adults, 15.01.012  Individual
Flow Cytometry, 15.01.002  Individual
Folate Testing, 15.01.024  Individual
Gamma-glutamyl Transferase, 15.01.021  Individual
General Inflammation Testing, 15.01.019  Individual
Helicobacter Pylori Testing, 15.01.032 Individual
Human Immunodeficiency Virus (HIV), 15.01.027  Individual
Identification Of Microorganisms Using Nucleic Acid Probes, 15.01.016  Individual
Immune Cell Function Assay, 15.01.010  Individual
Immunohistochemistry, 15.01.005  Individual
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies, 15.01.035  Individual
In Vitro Chemoresistance and Chemosensitivity Assays, 15.01.038  Individual
Intracellular Micronutrient Analysis, 15.01.041  Individual
Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease, 15.01.051  Individual
Lyme Disease Testing, 15.01.008  Individual
Metabolite Markers of Thiopurines Testing, 15.01.009  Individual
Nerve Fiber Density Testing, 15.01.022  Individual
Onychomycosis Testing, 15.01.037  Individual
Pancreatic Enzyme Testing for Acute Pancreatitis, 15.01.025  Individual
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing, 15.01.006  Individual
Pathogen Panel Testing, 15.01.043  Individual
Prescription Medication and Illicit Drug Testing in the Outpatient Setting, 15.01.046  Individual
Prostate Biopsy Specimen Analysis, 15.01.045  Individual
Salivary Hormone Testing, 15.01.028  Individual
Serum Biomarker Testing for Multiple Sclerosis and related Neurologic Disease, 15.01.052  Individual
Serum Testing for Evidence of Mild Traumatic Brain Injury, 15.01.023  Individual
Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease, 15.01.013  Individual
Serum Tumor Markers for Malignancies, 15.01.042  Individual
Testing For Alpha-1 Antitrypsin Deficiency, 15.01.048  Individual
Testing for Vector-borne Infections, 15.01.026  Individual
Testing of Homocysteine Metabolism-Related Conditions, 15.01.049  Individual
Testosterone, 15.01.017  Individual
Therapeutic Drug Monitoring for 5-Fluorouracil, 15.01.044  Individual
Thyroid Disease Testing, 15.01.003  Individual
Urinary Tumor Markers for Bladder Cancer, 15.01.050  Individual
Urine Culture Testing for Bacteria, 15.01.015  Individual
Venous and Arterial Thrombosis Risk Testing, 15.01.047  Individual
Vitamin B12 And Methylmalonic Acid Testing, 15.01.029  Individual

Utilization Management Update

• For dates of service on or after January 1, 2027, physical therapy and occupational therapy services will be reviewed by EviCore using Muskuloskeletal: Therapies clinical guideline.
• To submit a review, register and log in to the EviCore Provider’s Hub.

No updates this month.