Medical Policy and Coding Updates

Effective October 9, 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.

Medical necessity criteria added

• InterQual criteria added for psychiatric evaluations during mental health, eating disorder, and substance use disorder partial hospitalization program (PHP) treatment; for substance use evaluations during substance use disorder PHP; and for nutritional assessments during eating disorder PHP.
• Specified the clinician types authorized to perform each evaluation, ensuring consistency with those designated for the same evaluations in residential treatment settings.

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
  • Added duplex ultrasound as a requirement 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 September 1, 2026

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.

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.

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.

Revised medical policies
Effective July 1, 2026

Intraoperative Neurophysiologic Monitoring, 7.01.562  Individual | Group
Medical necessity criteria updated

• Cavernous sinus tumor removal, resection of epileptogenic brain tissue or tumor, and resection of tumors involving the auditory nerve are now included in the list of procedures for which intraoperative neurophysiologic monitoring (IONM) may be considered medically necessary.

Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use Disorders, 5.01.586  Individual | Group
Investigational criteria updated

• IV ketamine criteria revised to clarify that it is considered investigational in all settings and in conjunction with any service, and that any related visits or services during which IV ketamine is administered are also considered investigational.

Liver Transplant and Combined Liver-Kidney Transplant, 7.03.509  Individual | Group
Medical necessity criteria updated

• Unresectable colorectal cancer with liver metastases revised from investigational to may be considered medically necessary in highly selected individuals when criteria are met.

New pharmacy policies
Effective July 1, 2026

Chimeric Antigen Receptor Therapy for Multiple Myeloma, 8.01.543  Individual | Group
Policy renumbered

• This policy replaces Chimeric Antigen Receptor Therapy for Multiple Myeloma, 8.01.66, which is now deleted.

Medical necessity criteria removed

• Removed reference to non-formulary exception reviews.

Revised pharmacy policies
Effective July 1, 2026

Antidepressants: Pharmacy Medical Necessity Criteria for Brands, 5.01.520  Individual | Group
Medical necessity criteria added

• Auvelity (dextromethorphan and bupropion) may be considered medically necessary for the treatment of agitation associated with dementia due to Alzheimer’s disease when criteria are met.

Medical necessity criteria removed

• Removed reference to non-formulary exception reviews.

Drugs for Weight Management, 5.01.621  Individual | Group
Medical necessity criteria added

• Wegovy HD (semaglutide) injection may be considered medically necessary for chronic weight management when criteria are met.
• Foundayo (orforglipron) may be considered medically necessary for chronic weight management when criteria are met.

Medical necessity criteria updated

• Contrave, generic liraglutide, generic phentermine-topiramate extended release, Qsymia, Saxenda, Wegovy, Xenical, and Zepbound criteria updated to include Foundayo in the list of medications not to be used concurrently.

Medical necessity criteria removed

• Removed reference to non-formulary exception reviews.

Dupixent (dupilumab), 5.01.575  Individual | Group
Medical necessity criteria added

• Dupixent (dupilumab) may be considered medically necessary for the treatment of allergic fungal rhinosinusitis (AFRS) in individuals who have a history of sino-nasal surgery when criteria are met.

Medical necessity criteria updated

• Chronic spontaneous urticaria (CSU) criteria revised to lower the age requirement from 12 years to 2 years and older, and to update dosing limitations.
• Chronic rhinosinusitis with nasal polyposis criteria revised to clarify that diagnosis must be confirmed by physical examination, sinus computed tomography scan, or nasal endoscopy.

Gene Therapies for Thalassemia, 5.01.42  Individual | Group
Medical necessity criteria updated

• Casgevy (exagamglogene autotemcel) criteria revised to remove the upper age restriction of 35 years, expanding eligibility to individuals aged 12 years or older.
• Casgevy criteria revised from requiring no persistent aspartate transaminase (AST), alanine transaminase (ALT), or direct bilirubin greater than 2 times the ULN to requiring no persistent AST or ALT greater than 3 times the upper limit of normal (ULN), or direct bilirubin greater than 2.5 times the ULN.
• Casgevy criteria revised to include an additional option for documenting regular peripheral blood transfusions: a history of receiving at least 10 units of packed red blood cells per year over the previous 2 years.

Investigational criteria added

• Casgevy is considered investigational for any conditions not addressed in this policy or Pharmacologic Treatment of Sickle Cell Disease, 5.01.640.

Medical necessity criteria removed

• Removed reference to non-formulary exception reviews.

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

• Icotyde (icotrokinra) may be considered medically necessary for the treatment of moderate to severe plaque psoriasis when criteria are met.

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

• Atoncy (atomoxetine) may be considered medically necessary for the treatment of attention deficit hyperactivity disorder when criteria are met.
• Desmoda (desmopressin) may be considered medically necessary for the management of central diabetes insipidus when criteria are met.
• Brand clobetasol 0.025% now included in Topical Brand Corticosteroids.
• Quiofic (folic acid) and brand folic acid solution may be considered medically necessary when criteria are met.
• Byqlovi (clobetasol) now included in Brand Ophthalmic Corticosteroids.

Medical necessity criteria updated

• Linzess (linaclotide) for the treatment of functional constipation age requirement expanded from 6 to 17 years, to 2 to 17 years.
• Bronchitol (mannitol), Camzyos (mavacamten), Myqorzo (aficamtem), Soaanz (torsemide), Tryvio (aprocitentan), Vafseo (vadadustat), Viberzi (eluxadoline), Zunveyl (benzgalantamine) criteria now includes a quantity limit per 30 days.
• Zolymbus (bimatoprost) now includes a quantity limit of 30 single-dose containers per 30 days.
• Yartemlea (narsoplimab-wuug) now includes a dose limit of 370 mg twice weekly, and medication is prescribed by or in consultation with a hematologist or oncologist.

Medical necessity criteria removed

• Symjepi (epinephrine) has been discontinued.
• Quantity limit reviews no longer included in generic albuterol HFA, Auvi-Q, Epiduo, epinephrine, EpiPen, EpiPen Jr, and Neffy nasal spray as quantity limit reviews addressed in policy 5.01.656 -Drug Quantity Management.
• Generic prucalopride, Lokelma (sodium zirconium cyclosilicate), and Veltassa (patiromer).

Length of approval criteria updated

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

Medical Pharmacologic Treatment of Multiple Sclerosis, 5.01.644  Individual | Group
Medical necessity criteria added

• Ocrevus (ocrelizumab) may be considered medically necessary for the treatment of pediatric individuals with relapsing-remitting multiple sclerosis when criteria are met.

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

• Jakafi XR (ruxolitinib extended-release) may be considered medically necessary for the treatment of myelofibrosis, polycythemia vera, steroid-refractory acute graft-versus-host disease, or chronic graft-versus-host disease when criteria are met, with a maximum dose of 55 mg daily and a limit of 30 tablets per 30 days.
• Lifyorli (relacorilant) for the treatment of platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer when criteria are met.
• Evdi (trabectedin) may be considered medically necessary for the treatment of unresectable or metastatic liposarcoma or leiomyosarcoma in individuals who received a prior anthracycline.

Medical necessity criteria updated

• Xpovio (selinexor) no longer indicated for treatment of relapsed or refractory diffuse large B-cell lymphoma.
• Voranigo (vorasidenib) and Ogsiveo (nirogacestat) criteria now include a quantity limit per 30 days.
• Inqovi (decitabine and cedazuridine) criteria have been revised to include use in combination with venetoclax for newly diagnosed acute myeloid leukemia (AML) in individuals aged 75 years or older, or in those with comorbidities that preclude intensive induction chemotherapy.
• Abraxane (paclitaxel protein bound particles) and brand paclitaxel protein-bound particles now include indications for the treatment of platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer when criteria are met.
• Evomela (melphalan) for use as a high-dose conditioning treatment prior to hematopoietic progenitor (stem) cell transplantation removing the requirement in individuals with multiple myeloma.

Length of approval criteria updated

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

Pharmacologic Treatment of Atopic Dermatitis, 5.01.628  Individual | Group
Medical necessity criteria added

• Adquey (difamilast) may be considered medically necessary for the treatment of atopic dermatitis when criteria are met.

Medical necessity criteria updated

• Adbry (tralokinumab-ldrm) criteria revised to clarify maintenance dose limits in individuals aged 12 to 17 years, specifying a maintenance dose of 150 mg every other week.
• Ebglyss (lebrikizumab-lbkz) criteria revised to include requirement that the individual weighs at least 40 kg.

Medical necessity criteria removed

• Elidel (pimecrolimus) and Protopic (tacrolimus) have been discontinued.

Length of approval criteria updated

• Removed reference to non-formulary exception reviews.

Pharmacologic Treatment of Bladder Cancer, 5.01.632  Individual | Group
Medical necessity criteria updated

• Adstiladrin (nadofaragene firadenovec-vncg) criteria updated to include coverage for non–muscle invasive bladder cancer with papillary tumors (+Ta/T1) without carcinoma in situ, and to remove the requirement for an Eastern Cooperative Oncology Group (ECOG) performance status of 2 or less.
• Anktiva criteria revised to remove the requirement for an ECOG performance status of 2 or less.

Length of approval criteria updated

• Removed reference to non-formulary exception reviews.

Pharmacologic Treatment of Neuropathy, Fibromyalgia, and Seizure Disorders, 5.01.521  Individual | Group
Medical necessity criteria added

• Relgaabi (gabapentin) 200 mg may be considered medically necessary for the treatment of neuropathic pain and seizure disorder when criteria are met.
• Milnacipran may be considered medically necessary for the treatment of fibromyalgia when criteria are met with a quantity limit of 60 tablets per 30 days.

Medical necessity criteria updated

• Savella (milnacipran) now requires trial of generic milnacipran and includes a quantity limit of 60 tablets per 30 days.
• Tonmya (cyclobenzaprine) now includes a quantity limit of 60 tablets per 30 days.

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 added

• Icotyde (icotrokinra) may be considered medically necessary for the treatment of moderate to severe plaque psoriasis when criteria are met.

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

• Itvisma (onasemnogene abeparvovec-brve) may be considered medically necessary for the treatment of SMA when criteria are met.

Medical necessity criteria updated

• Evrysdi (risdiplam) and Spinraza (nusinersen) criteria now preclude previous treatment with Itvisma (onasemnogene abeparvovec-brve).

Length of approval criteria updated

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

Effective July 1, 2026

Medical Necessity Criteria for the Essentials Formulary, 5.01.657
Policy archived

• Policy archived due to duplication with other policies and the decision to manage Eliquis, a non-formulary drug for Essentials formulary, under Coverage Criteria for Excluded and Non-Formulary Drugs, 5.01.572.

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

Effective July 1, 2026

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

1044T, 1045T, 1046T, 1047T, 1048T, 1049T

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

J9062

Chimeric Antigen Receptor Therapy for Multiple Myeloma, 8.01.543  Individual | Group
Now requires review for medical necessity and prior authorization.

J9053

Facet Arthroplasty, 7.01.120  Individual | Group
Now considered investigational.

C1609

Gene Therapies for Rare Diseases, 5.01.642  Individual | Group
Now requires review for medical necessity and prior authorization.

J3386

IL-5 Inhibitors, 5.01.559  Individual | Group
Now requires review for medical necessity and prior authorization.

J2361

Immune Globulin Therapy, 8.01.503  Individual | Group
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.

J1577

Intravenous and Replacement Products, 5.01.630  Individual | Group
Now requires review for medical necessity and prior authorization.

A9574

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

A9574, J1289

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

J9053

Non-Covered Experimental/Investigational Services, 10.01.533  Individual | Group
Now considered investigational.

C8014, 1026T, 1027T, 1028T, 1029T, 1030T, 1031T, 1032T, 1033T, 1034T, 1035T, 1036T, 1037T, 1038T, 1039T, 1041T, 1042T, 1043T, 1050T, 1051T, 1052T, 1053T

Pharmacologic Treatment of Psoriatic Arthritis, 5.01.645  Individual | Group
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  Individual | Group
Now requires review for medical necessity and prior authorization.

Q5164

Pharmacotherapy of Spinal Muscular Atrophy (SMA), 5.01.574  Individual | Group
Now requires review for medical necessity.

J3405

Prescription Digital Therapeutics, 3.03.06  Individual | Group
Now considered investigational.

E1905

Use of Granulocyte Colony Stimulating Factors (G-CSF), 5.01.551  Individual | Group
Now requires review for medical necessity and prior authorization.

Q5169

Vascular Endothelial Growth Factor Receptor Inhibitors for Ocular Disorders, 5.01.620  Individual | Group
Now requires review for medical necessity and prior authorization.

Q5168

Xolair, 5.01.513  Individual | Group
Now requires review for medical necessity and prior authorization.

Q5154

Removed codes
Effective July 1, 2026

Laboratory Testing Investigative, 2.04.520  Individual | Group
No longer requires review.

0557U

Percutaneous Electrical Nerve Field Stimulation for Disorders of Gut Brain Interaction, 2.01.106  Individual | Group
No longer requires review.

0720T

Pharmacotherapy of Spinal Muscular Atrophy (SMA), 5.01.574  Individual | Group
No longer requires review.

C9309

Prescription Digital Therapeutics, 13.01.500  Individual | Group
No longer requires review.

E1905

Revised codes
Effective September 1, 2026

Site of Service Ambulatory Service Center (ASC): Select Surgical Procedures for Adults, 11.01.525  Individual | Group
Upper Gastrointestinal Endoscopy (UGI) in Adults, 2.01.533  Individual | Group
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

43235, 43238, 43239, 43242

Effective September 4, 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.