Medical Policy and Coding Updates

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 specifies 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 Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Radiation Oncology. As part of Carelon’s 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 Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Genetic Testing. As part of Carelon’s 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 of 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, and 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 2 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 October 1, 2026

Deep Brain Stimulation, 7.01.609  Individual | Group
Policy renumbered

• This policy replaces Deep Brain Stimulation, 7.01.63.

Medical necessity criteria updated

• Contraindications to deep brain stimulation for obsessive-compulsive disorder and the use of deep brain stimulation in conjunction with transcranial magnetic stimulation or any other neuromodulation modality were incorrectly labeled as investigational and are now correctly labeled as not medically necessary.

Revised medical policies
Effective October 1, 2026

Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation for Benign Prostatic Hyperplasia, 2.01.544  Individual | Group
Medical necessity criteria updated

• Rezum and Aquablation may be considered medically necessary for the treatment of refractory urinary retention secondary to benign prostatic hyperplasia requiring an indwelling catheter or intermittent self-catheterization.
• For transurethral waterjet ablation, the maximum prostate gland volume requirement was expanded to greater than or equal to 30 mL to less than or equal to 150 mL.

Wilderness Therapy/Outdoor Behavioral Healthcare Residential Wilderness Programs, 3.01.522  Individual | Group
Medical necessity criteria updated

• Initial psychiatric evaluation may be completed within 2 calendar days after admission.
• Subsequent psychiatric evaluations are required at least once every 10 days.

Revised pharmacy policies
Effective October 1, 2026

Botulinum Toxins, 5.01.512  Individual | Group
Medical necessity criteria updated

• Xeomin (incobotulinumtoxinA) criteria for treatment of upper limb spasticity no longer require that spasticity is not caused by cerebral palsy.

Medical necessity criteria removed

• Removed reference to non-formulary exception reviews.

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

• Zilbrysq (zilucoplan) criteria for the treatment of generalized MG now include Imaavy (nipocalimab-aahu) in the list of preferred alternatives.
• Bkemv (eculizumab-aeeb), Epysqli (eculizumab-aagh), Soliris (eculizumab), and Ultomiris (ravulizumab-cwvz) criteria for the treatment of generalized MG no longer require that the individual is receiving or has had a trial of pyridostigmine.

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

• Added Immgolis (golimumab-sldi) may be considered medically necessary when criteria equivalent to Simponi (golimumab) SC are met.

Medical necessity criteria updated

• Updated Entyvio (vedolizumab) SC and Zeposia (ozanimod) adding Immgolis (golimumab-sldi) to list of preferred alternatives.
• Updated Renflexis (infliximab-abda) from a non-preferred product to a preferred product.
• Updated Riabni, Rituxan, Rituxan Hycela, Ruxience, and Truxima for the treatment of RA adding Renflexis (infliximab-abda) to list of preferred alternatives.
• Updated non-preferred infliximab products, infliximab (Janssen – unbranded) and Remicade (infliximab), adding Renflexis (infliximab-abda) to list of preferred alternatives.

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

• Baxfendy (baxdrostat) may be considered medically necessary for the treatment of hypertension when criteria are met.
• Generic dextromethorphan hydrobromide and quinidine sulfate may be considered medically necessary for the treatment of pseudobulbar affect when criteria are met.

Medical necessity criteria updated

• Tryvio (aprocitentan) criteria now require that the individual is aged 18 years or older.
• Zelsuvmi (berdazimer) criteria no longer include brand cantharidin in the list of preferred alternatives.
• Nuedexta criteria now require a trial of generic dextromethorphan hydrobromide and quinidine sulfate.

Medical necessity criteria removed

• Journavx (suzetrigine) quantity limit criteria moved to policy 5.01.656 Drug Quantity Management.
• Alocril, Aemcolo, Alomide, Androderm, Asacol HD, brand ketorolac tromethamine nasal spray, Daypro, Delzicol, Duexis, Evoclin, Extina, Flagyl, Fortesta, Gelnique, Jesduvroq, Locoid, Locoid Lipocream, Luxiq, Lyvispah, Mentax, Olux, Olux-E, Ortikos, Pediapred, Pennsaid, Pizensy, Tekturna HCT, Temovate, Teveten HCT, Tivorbex, Tridesilon, Verdeso, Vesicare LS, Vimovo, Vostally, Widaplik, Xolegel, Zetonna, and Zolpimist have been discontinued.
• Coverage criteria for brand baclofen solution, brand baclofen suspension, brand diclofenac potassium for oral solution, brand esomeprazole, and brand cantharidin have been removed.

Pharmacologic Prevention and Treatment of HIV and AIDS, 5.01.588  Individual | Group
Medical necessity criteria removed

• Coverage criteria for Apretude (cabotegravir extended-release injectable suspension), Descovy (emtricitabine and tenofovir alafenamide), Rukobia (fostemsavir), Sunlenca (lenacapavir), Trogarzo (ibalizumab), and Yeztugo (lenacapavir) have been removed.
• Removed reference to non-formulary exception reviews.

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

• Renflexis (infliximab-abda) is now a preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria include Renflexis (infliximab-abda) in the list of preferred alternatives.

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

• Immgolis Intri (golimumab-sldi) IV may be considered medically necessary when criteria equivalent to Simponi (golimumab) IV are met.
• Immgolis (golimumab-sldi) may be considered medically necessary when criteria equivalent to Simponi (golimumab) SC are met.

Medical necessity criteria updated

• Renflexis (infliximab-abda) is now a preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria now include Renflexis (infliximab-abda) in the list of preferred alternatives.

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

• Renflexis (infliximab-abda) is now a preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria now include Renflexis (infliximab-abda) in the list of preferred alternatives.

Medical necessity criteria added

• Immgolis (golimumab-sldi) may be considered medically necessary when criteria equivalent to Simponi (golimumab) SC are met.
• Immgolis Intri (golimumab-sldi) IV may be considered medically necessary when criteria equivalent to Simponi (golimumab) IV are met.

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

• Immgolis (golimumab-sldi) SC may be considered medically necessary when criteria equivalent to Simponi (golimumab) SC are met.

Medical necessity criteria updated

• Entyvio (vedolizumab) SC and Zeposia (ozanimod) criteria now include Immgolis (golimumab-sldi) SC in the list of preferred alternatives.
• Renflexis (infliximab-abda) is now a preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria include Renflexis (infliximab-abda) in the list of preferred alternatives.

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

• Renflexis (infliximab-abda) is now a preferred product.
• Infliximab (Janssen – unbranded) and Remicade (infliximab) criteria now include Renflexis (infliximab-abda) in the list of preferred alternatives.
• Imaavy (nipocalimab-aahu) is now a preferred product for treatment of generalized myasthenia gravis (MG).
• Rystiggo (rozanolixizumab-noli) and Uplizna (inebilizumab-cdon) criteria for the treatment of generalized MG now include Imaavy (nipocalimab-aahu) in the list of preferred alternatives.

Medical necessity criteria added

• Trutakna (atacicept-vymj) may be considered medically necessary to reduce proteinuria in adults with primary immunoglobulin A nephropathy at risk for disease progression when criteria are met.

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

• Criteria for all rituximab products for the treatment of rheumatoid arthritis now include Renflexis (infliximab-abda) in the list of preferred infliximab alternatives.

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

• Vegzelma (bevacizumab-adcd) is now a preferred product and included in the list of preferred alternatives for Alymsys, Avastin, Avzivi, and Jobevne.

Medical necessity criteria removed

• Removed reference to non-formulary exception reviews.

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

• Ahzantive (aflibercept-mrbb), Enzeevu (aflibercept-abzv), Eydenzelt (aflibercept-boav), Opuviz (aflibercept-yszy), and Yesafili (aflibercept-jbvf) may be considered medically necessary when the same criteria as Eylea (aflibercept) are met.
• Nufymco (ranibizumab-leyk) and Ranluspec (ranibizumab-hkdz) may be considered medically necessary when the same criteria as Lucentis (ranibizumab) are met.

Medical necessity criteria updated

• Beovu (brolucizumab-dbll), Eylea (aflibercept), Eylea HD (aflibercept), and Susvimo (ranibizumab) criteria include Cimerli (ranibizumab-eqrn), Nufymco (ranibizumab-leyk), and Ranluspec (ranibizumab-hkdz) in the list of preferred alternatives.
• Pavblu (aflibercept-ayyh) criteria expanded to include treatment of ROP.
• Byooviz (ranibizumab-nuna) criteria expanded to include treatment of diabetic macular edema and diabetic retinopathy.
• All drugs listed in the policy are considered investigational when used in combination with another drug in the policy for the same treated eye. Individual lists of drugs that should not be used concurrently have been removed.

Medical necessity criteria updated

• Removed reference to non-formulary exception reviews.

No updates this month.

Effective October 1, 2026

Prescription Digital Therapeutics, 7.01.63

• This policy is replaced with Deep Brain Stimulation, 7.01.609.

Added codes
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 October 1, 2026

ALK Tyrosine Kinase Inhibitors, 5.01.638  Individual | Group
Now requires review for medical necessity and prior authorization.

J3406

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

A2046, A2047, A2048, A2049, A2050, Q4207, Q4223, Q4243.

Denosumab Products, 5.01.658  Individual | Group
Now requires review for medical necessity and prior authorization.

Q5173

Laboratory Testing Investigational Services, 2.04.520  Individual | Group
Now considered investigational.

0662U, 0663U, 0664U, 0680U, 0681U, 0682U, 0684U, 0685U, 0687U, 0692U, 0695U.

Magnetic Resonance Imaging-Guided Focused Ultrasound, 7.01.109  Individual | Group
Now considered investigational.

1099T

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

J9362, J9033

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

1054T, 1055T, 1057T, 1058T, 1059T, 1060T, 1061T, 1062T, 1063T, 1064T, 1065T, 1066T, 1067T, 1068T, 1069T, 1070T, 1071T, 1072T, 1073T, 1074T, 1075T, 1076T, 1077T, 1078T, 1079T, 1080T, 1083T, 1084T, 1085T, 1086T, 1087T, 1089T, 1090T, 1091T, 1092T, 1093T, 1094T, 1096T, 1097T, 1098T, 1100T, 1101T, 1102T, 1103T, 1104T, 1105T, 1106T, 1107T, G0685

Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used with Autologous Bone Marrow), 8.01.52  Individual | Group
Now considered investigational.

1095T

Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy, 7.01.588  Individual | Group
Now considered investigational.

1088T

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

C1604

Pharmacologic Treatment of Transthyretin-Mediated Amyloidosis, 5.01.593  Individual | Group
Now requires review for medical necessity.

C9311

Surgical Treatments for Lymphedema and Lipedema, 7.01.567  Individual | Group
Now requires review for medical necessity and prior authorization.

1081T, 1082T

Therapeutic Radiopharmaceuticals in Oncology, 6.01.525  Individual | Group
Now requires review for medical necessity and prior authorization.

A9613

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

Q5172

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

Q5149, Q5150, Q5153, Q5155

Removed codes
Effective November 6, 2026

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

28291

Effective October 1, 2026

Bioengineered Skin and Soft Tissue Substitutes, 7.01.582  Individual | Group
No longer requires review.

Q4158

Cosmetic and Reconstructive Services, 10.01.514  Individual | Group
No longer requires review.

54660, V2623, 21086

Laboratory Testing Investigational Services, 2.04.520  Individual | Group
Code terminated

0556U

Pharmacologic Prevention and Treatment of HIV and AIDS, 5.01.588  Individual | Group
No longer requires review for medical necessity.

J1746, J1961, J0738, J0739, J0750, J0751, J0752, J0799

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.

J3405

Effective November 6, 2026

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

34717, 34718

Effective October 1, 2026

Deep Brain Stimulation, 7.01.609  Individual | Group
Now requires prior authorization. Review for medical necessity is still required.

61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, L8680, L8685, L8686, L8687, L8688

Now requires review for medical necessity.

C1767, C1778, C1820

No updates this month.

No updates this month.

Effective January 1, 2026

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 (such as 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.