*NEW POLICY* Prior Authorization of Physical and Occupation Therapy Services

Effective January 1, 2026, Physical Therapy and Occupational Therapy Services will be reviewed for medical necessity for Medicare Advantage plans, for visits after the 14th visit per episode of care, by the BCBSRI Physical and Occupational Therapy Services vendor. As a result of this program implementation, some medical policies received minor updates.

The following policies instruct the use of Unlisted CPT Codes to represent the services, due to a lack of more specific coding:

• Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
• Sympathetic Therapy for the Treatment of Pain 

The following policy will address coverage for Commercial Products, as coverage for Medicare will be addressed in the Prior Authorization of Physical and Occupational Therapy Services policy:

• Sensory Integration Therapy and Auditory Integration Therapy 

For additional details related to this new policy, please click here. 

Baroreflex Stimulation Devices 

Effective January 1, 2026, the medical criteria will be revised to address this service for only the treatment of heart failure for Medicare Advantage plans and commercial products, as the device is no longer marked for treatment-resistant hypertension. For additional details related to this policy, please click here. 

Molecular Testing for the Management of Pancreatic Cysts and Solid Pancreaticobiliary Lesions

Effective January 1, 2026, PathfinderTG® molecular testing will change from requiring prior authorization to not covered for Medicare Advantage plans and not medically necessary for commercial products. For additional details related to this policy, please click here. 

Prior Authorization via Web-Based Tool for Procedures            

Effective January 1, 2026:

• Prior authorization will be removed from CPT codes 11971 and 64575 for Medicare Advantage plans and commercial products.
• The medical criteria source for CPT code 11971 will change from medical criteria in the online authorization tool based on National Coverage Determination to standard medical criteria in the online authorization tool for Medicare Advantage plans only. 

For additional details related to this policy, please click here. 

New Technology and Miscellaneous Services

Effective January 1, 2026, CPT code 0395T will change from requiring prior authorization for Medicare Advantage plans and not medically necessary for commercial products to covered for Medicare Advantage plans and commercial products. For additional details related to this policy, please click here. 

Genetic Testing Services      

Effective November 1, 2025, CPT code 86316 will be moved to medical policy, Genetic Testing Services from three medical policies: 1. Serum Tumor Markers for Breast and Gastrointestinal Malignancies, 2. Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer, 3. Urinary Biomarkers for Cancer Screening, Diagnosis and Surveillance. There will be no change in coverage for Medicare Advantage plans or commercial products; only the policy source will change. For additional details related to this policy, please click here. 

Plasma-Based Genomic Profiling (Liquid Biopsy) in Solid Tumors 

Effective January 1, 2026:   

• CPT codes 0326U/0409U will continue to require prior authorization; however, the medical criteria will move from this policy to being available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. Coverage guidance will be available in the medical policy, Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA).
• There are no other changes for the remaining test(s) in this medical policy for Medicare Advantage plans or commercial products. 

For additional details related to this policy, please click here. 

Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders 

Effective January 1, 2026:   

• CPT codes 0425U/0426U will continue to require prior authorization; however, the medical criteria will move from this policy to being available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. Coverage guidance will be available in the medical policy, Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA).
• There are no other changes for the remaining test(s) in this medical policy for Medicare Advantage plans or commercial products.

For additional details related to this policy, please click here. 

Prostatic Urethral Lift

Effective December 1, 2025, for Medicare Advantage plans and commercial products:   

• CPT/HCPCS Codes 52441, 52442, C9739, C9740 will change from requiring prior authorization to being covered.
• There are no other codes in this policy.

For additional details related to this policy, please click here. 

Transcatheter Mitral Valve Repair or Replacement (TMVR)

Effective January 1, 2026, the policy statement for commercial products for Transcatheter Edge-to-Edge Repair has been clarified and the overall policy has been reorganized by service. For additional details related to this policy, please click here.

Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA)

Effective January 1, 2026:    

• CPT 0051U: Authorization will be removed from Medicare Advantage plans and commercial products; service will be covered.
• CPT 0320U: Medical necessity criteria will be changed to LCD criteria and will be available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.
• CPT 0326U: The location of medical necessity criteria will be updated to reflect criteria is available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.
• CPT 0409U, 0425U, 0426U: Medical necessity criteria will be changed to InterQual criteria and will be available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.
• CPT 0526U, 0528U: Authorization will be removed from Medicare Advantage plans and commercial products; service will be not covered for Medicare Advantage plans and not medically necessary for commercial products.
• CPT 0538U, 0539U, 0562U, 0567U: Medical necessity criteria will be changed to InterQual criteria and will be available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.
• CPT 0571U: Medical necessity criteria will be changed to LCD criteria and will be available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. 

For additional details related to this policy, please click here. 

Genetic Testing Services

Effective November 1, 2025: 

The medically necessary diagnosis editing information for CPT code 86316 will be removed from the following three medical policies and will be addressed in the Genetic Testing Services policy. There is no change to the content at this time, just the location.

• Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
• Serum Tumor Markers for Breast and Gastrointestinal Malignancies
• Urinary Biomarkers for Cancer Screening, Diagnosis and Surveillance

Effective January 1, 2026:    

• CPT 81287: Prior authorization will be removed, and a covered diagnosis edit will be applied to Medicare Advantage plans.
• CPT 81332: Authorization bypass will be added for diagnosis code E88.01, Alpha-1-antitrypsin deficiency for Medicare Advantage plans and commercial products, all other diagnosis codes continue to need authorization.
• HCPCS S3854: Prior authorization will be added to Medicare Advantage plans.
• CPT 81170, 81305: A covered diagnosis edit will be applied to Medicare Advantage plans and commercial products and prior authorization will be removed.
• CPT 81351, 81352: Authorization bypass will be added for specific diagnosis codes for Medicare Advantage plans and commercial products, all other diagnosis codes continue to need authorization.
• CPT 81249, 81302: Prior authorization will be removed from Medicare Advantage plans; service will not be covered.
• CPT 81504: Prior authorization will be removed from commercial products; service will be not medically necessary.

For additional details related to this policy, please click here.

Prior authorization for cardiology and radiology services   

Effective January 1, 2026, prior authorization will be removed from the following CPT and HCPCS codes for Medicare Advantage plans and commercial products:

78013-78016, 78018, 78070-78072, 78075, 78102, 78103, 78140, 78185, 78195, 78201, 78202, 78215, 78216, 78226, 78230-78232, 78258, 78261, 78262, 78264-78266, 78278, 78290, 78291, 78300, 78305, 78306, 78315, 78445, 78457, 78458, 78579, 78580, 78582, 78597, 78598, 78600, 78601, 78605, 78606, 78610, 78630, 78635, 78645, 78650, 78660, 78700, 78701, 7870778709, 78725, 78730, 78740, 78761, 78800, 78802-78804, 93303, 93304, 93306-93308, 93312-93317, 93319, 0439T, C8921, C8922-C8926, C8928-C8930, C9762, C9763.  

For additional details related to this policy, please click here.

Islet Transplantation for Chronic Pancreatitis 

Effective January 1, 2026, services will be covered for both Medicare and Commercial Products. For additional details related to this policy, please click here.