*Implementation of New Medical Policy is on Hold: Joint Replacement, Shoulder
Further Information to be provided in a future update.
Effective November 1, 2026, we will continue to utilize the medical criteria found in the online authorization tool instead of the medical criteria in this new, draft policy for Medicare Advantage Plans and Commercial Products for CPT codes 23470 and 23472. Further Information will be provided in a future update.
Evaluation of Biomarkers for Alzheimer’s Disease
Effective January 1, 2027, for Medicare Advantage plans and commercial products, there will be a revision to the medical necessity criteria in the policy. The title of the policy will also change to Evaluation of Cerebrospinal Fluid, Urine and Plasma Tests for Alzheimer’s Disease. There will be no other changes to this policy. For additional details related to this policy, please click here.
Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer changing
Effective January 1, 2027, for Medicare Advantage plans and commercial products, there will be a revision to the medical necessity criteria in the policy. Additionally, CPT 0154U will be added to this policy and will require prior authorization for Medicare and commercial utilizing the medical criteria in this policy. The title of this Medical Policy will also change to Genetic Variant Testing (Including Liquid Biopsy) for Targeted Treatment in Advanced Cancer. There will be no other changes to this policy. For additional details related to this policy, please click here.
Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease
Effective January 1, 2027, the coverage for lipoprotein(a) testing, CPT code 83695, will be considered medically necessary as a single (once per lifetime) measurement in individuals aged 18 and older for Medicare Advantage plans and commercial products. For additional details related to this policy, please click here.
Removal of Implantable Devices
Effective January 1, 2027, prior authorization will no longer be required for Medicare Advantage plans or recommended for commercial products for CPT code 0661T. For additional details related to this policy, please click here.
Saturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer
Effective January 1, 2027, the service in this policy will change to being covered for Medicare Advantage plans and commercial products. For additional details related to this policy, please click here.
Invasive Prenatal (Fetal) Diagnostic Testing
Effective January 1, 2027, for Medicare Advantage plans and commercial products, there will be a revision to the medical necessity criteria in the policy. There will be no other changes to this policy. For additional details related to this policy, please click here.
Orthopedic Applications of Stem Cell Therapy
Effective January 1, 2027, CPT 20999 is being added to this policy for Medicare Advantage plans and commercial products where it will be not covered for Medicare Advantage plans and not medically necessary for commercial products. There will be no other changes to this policy. For additional details related to this policy, please click here.
Superficial Radiation Therapy and Electronic Brachytherapy for Non-Melanoma Skin Cancer (former title: Electronic Brachytherapy for Non-Melanoma Skin Cancer)
For Medicare Advantage plans only, effective January 1, 2027, the policy will be updated to include Superficial Radiation Therapy. As a result, the new title will be Superficial Radiation Therapy and Electronic Brachytherapy for Non-Melanoma Skin Cancer. CPT codes 77436 and 77438 will change to covered for Medicare Advantage plans. Additionally, CPT code 77437 will change to covered for Medicare Advantage plans when filed with the appropriate modifier and covered diagnosis codes. There will be no change to commercial products. For additional details related to this policy, please click here.
Prior authorization of physical and occupational therapy services
Effective upon renewal on or after January 1, 2027, physical therapy and occupational therapy services will be reviewed for medical necessity for fully-funded commercial products, 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 will be impacted.
The following policies will be archived effective January 1, 2027 because the services and CPT/HCPCS codes in these policies will be reviewed for medical necessity:
- Sensory Integration Therapy and Auditory Integration Therapy
- Electrical Stimulation and Electromagnetic Therapy for Wound Treatment
The following policy will address the applicable CPT and ICD-10-CM code combinations that will be exempt from the requirements in the medical policy above, Physical Therapy and Occupational Therapy Services:
- Mastectomy Treatment, Breast Reconstruction and Hospital Stays Mandate
For additional details related to this policy, please click here.
Biomarker Testing Mandate
Effective January 1, 2027:
- CPT code 81312: Prior authorization will be removed from Medicare Advantage plans and commercial products; service will be covered.
- CPT code 81348: Medical necessity criteria will change to the criteria in the online authorization tool for Medicare Advantage plans and commercial products.
- CPT codes 81234, 81244, 81271, 81331, 81349, 81364:
- Medicare Advantage plans: Prior authorization will be removed, service will be not covered.
- Commercial products: Prior authorization will be removed; service will be covered.
- CPT code 81595: Prior authorization will be removed from Medicare Advantage plans and commercial products; service will be covered with specific diagnosis codes.
- For the following CPT codes, prior authorization will be removed from Medicare Advantage plans and service will be not covered:
- 81161, 81200, 81203, 81228, 81242, 81252, 81255, 81260, 81303, 81304, 81324, 81325, 81326, 81330 81361, 81363, and 81448
- HCPCS code S3841: Medical necessity criteria will change to the criteria in this policy for Medicare Advantage plans and commercial products.
- CPT codes 0564U, 0578U: Medical necessity criteria will change 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.
Removal of Implantable Devices
Effective January 1, 2027, all CPT codes in the medical policy, Removal of Implantable Devices, will no longer require prior authorization for Medicare Advantage Plans or Commercial Products. The applicable updates in this policy will also be reflected in the related medical policies, Prior Authorization of Services, Treatments or Procedures and New Technology and Miscellaneous Services. For additional details related to this policy, please click here.