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Blue Cross Blue Shields of Wyoming

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Reimbursement Reminders

Reimbursement Update

Blue Cross Blue Shield of Wyoming is committed to providing you with updates on upcoming policy and reimbursement changes. The following reimbursement policy reminders have been communicated in recent provider updates:

  • Effective, 9/1/24, BCBSWY is updating our ASC rates and rules. ASC rates can be found in the Availity portal under the BCBSWY resources payer space.
  • Effective 9/1/2024, infusion pumps (E0779, E0780, and E0781) will be reimbursed as a monthly rental instead of a daily payment. For services after 9/1/2024, if the amount that BCBSWY has paid for the pump exceeds our purchase allowance, we will deny additional claims. Services prior to 9/1/2024 may be considered in this calculation.
  • Effective 10/1/2024, BCBSWY will implement a 5% reduction in allowed for traditional radiology services, excluding oncology.

Medical policy updates are now available.

To view upcoming policy changes please visit: Medical Policy Updates – Blue Cross Blue Shield of Wyoming (bcbswy.com)

Prevent rejection when submitting medical records through Availity

Reminder, medical records submitted through Availity need to include a claim’s adjustment form or other documentation stating why the medical records are being submitted. If there is no claim adjustment form, the medical records will be rejected and will need to be resubmitted with documentation.

Provider Directory Validation Reminder

You can find the Provider Directory Validation guide under the Provider Resources section on the right rail of the website. Providers can use the Directory Validation tool on the Availity Portal to find NPI and tax ID combinations.

The No Surprises Act (NSA) requires you confirm this information every 90 days.

Confirm Today

Early Closure – Wed. July 24

In celebration of Cheyenne Day, BCBSWY will be closing at noon next Wednesday, July 24th.

Medical Policy Updates

View any medical policy or medical necessity criteria changes that will be implemented in the next 60 days or more.

  • BCBSWY requires prior authorization for certain health care services, treatments, prescription drugs, and durable medical equipment (DME) before a member can receive them, except in emergency.
  • Prior authorization is based on BCBSWY medical policy. Medical policy and criteria changes that will be implemented in the next 60 days are listed below.
  • This information is not intended to instruct providers or members on benefit changes or authorization requirements. Members can login to YourWyoBlue.com to search prior authorization requirements for their benefit plan. Providers can learn more about prior authorization requirements here →
  • This page is not valid for FEP members.
  • This page is only valid for members with BCBSWY membership and not other Blue plans

The BCBSWY Membership Prefixes are:

QWY YWY ZRW ZSD ZSF ZSH ZSK ZSP ZYW
Medical Policy Updates
Use the Policy Number, Policy Title, or CPT Codes to find and view the full medical policy.
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Policy # Policy Title Change Type Summary of Changes Effective Date Provider Notification Date
11.01.119 Braces and Supports DELETE Archiving the criteria. 9/29/25 7/29/25
6.01.025 Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 9/29/25 7/29/25
6.01.029 MRI Detection of Breast Cancer DELETE Archiving the criteria. 9/28/25 7/28/25
12.01.042 Oncology Immunotherapy UPDATE Updated policy information, including updated policy position information. 9/24/25 7/22/25
7.01.100 Bone Morphogenetic Protein UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 9/22/25 7/22/25
7.01.104 Subtalar Arthroereisis UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  There is no change to the policy position statement listed. 9/22/25 7/22/25
7.01.107 Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  There is no change to the policy position statement listed. 9/22/25 7/22/25
7.01.108 Artificial Intervertebral Disc: Cervical Spine UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 9/22/25 7/22/25
7.01.113 Bioengineered Skin and Soft Tissue Substitutes UPDATE Clinical evidence to support the policy position reviewed, content on nerve wraps and references added. GraftJacket and AlloMend removed from breast reconstruction policy statement as materials are not evaluated for this indication. All other policy statements unchanged. 9/22/25 7/22/25
7.01.118 Surgical Treatment of Femoroacetabular Impingement UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  Minor editorial revisions to policy guidelines; intent unchanged. Policy statements unchanged. 9/22/25 7/22/25
7.01.120 Facet Arthroplasty UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 9/22/25 7/22/25
7.01.126 Image-Guided Minimally Invasive Decompression for Spinal Stenosis UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 9/22/25 7/22/25
7.01.130 Axial Lumbosacral Interbody Fusion UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 9/22/25 7/22/25
7.01.149 Amniotic Membrane and Amniotic Fluid UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  NuShield added to existing medically necessary policy statement for the treatment of nonhealing diabetic lower-extremity ulcers based on RCT evidence. Otherwise, policy statements unchanged. 9/22/25 7/22/25
7.01.015 Meniscal Allografts and Other Meniscal Implants UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 9/22/25 7/22/25
7.01.025 Spinal Cord and Dorsal Root Ganglion Stimulation UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 9/22/25 7/22/25
7.01.048 Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 9/22/25 7/22/25
7.01.058 Intraoperative Neurophysiologic Monitoring UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 9/22/25 7/22/25
7.01.063 Deep Brain Stimulation UPDATE Clinical evidence to support the policy position reviewed and references added. Evidence review and investigational policy statement added for adaptive deep brain stimulation in Parkinson disease. 9/22/25 7/22/25
7.01.069 Sacral Nerve Neuromodulation/Stimulation UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 9/22/25 7/22/25
7.01.078 Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions UPDATE Clinical evidence to support the policy position reviewed and references added. Minor editorial refinements to listed order of policy statements; intent unchanged. 9/22/25 7/22/25
7.01.080 Hip Resurfacing UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 9/22/25 7/22/25
7.01.087 Artificial Intervertebral Disc: Lumbar Spine UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 9/22/25 7/22/25
7.01.093 Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency-Coblation (Nucleoplasty) UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 9/22/25 7/22/25
8.03.009 Vertebral Axial Decompression UPDATE Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. 9/22/25 7/22/25
12.01.079 Alhemo NEW Implementation of NEW guidelines. 10/1/25 7/22/25
12.01.080 Sensipar NEW Implementation of NEW guidelines. 10/1/25 7/22/25
12.01.081 Vanrafia NEW Implementation of NEW guidelines. 10/1/25 7/22/25
12.01.008 Xgeva - Oncology UPDATE Updated policy information, including updated policy position information. 9/22/25 7/21/25
12.01.009 Prolia - Osteoporosis UPDATE Updated policy information, including updated policy position information. 9/22/25 7/21/25
12.01.055 Xolair UPDATE Updated policy information, including updated policy position information. 9/22/25 7/21/25
12.01.039 Rituxan Oncology - Rituxan Hycela UPDATE Updated policy information, including updated policy position information. 9/22/25 7/21/25
7.01.149 Amniotic Membrane and Amniotic Fluid UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  NuShield added to existing medically necessary policy statement for the treatment of nonhealing diabetic lower-extremity ulcers based on RCT evidence. Otherwise, policy statements unchanged. 9/8/25 7/8/25
1.01.010 Continuous Passive Motion in the Home Setting UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  There is no change to the policy position statement listed. 9/8/25 7/8/25
2.01.100 Dry Needling of Trigger Points for Myofascial Pain UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 9/8/25 7/8/25
2.01.054 Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  There is no change to the policy position statement listed. 9/8/25 7/8/25
2.01.083 Interventions for Progressive Scoliosis UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  There is no change to the policy position statement listed. 9/8/25 7/8/25
2.01.098 Orthopedic Applications of Platelet-Rich Plasma UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  There is no change to the policy position statement listed. 9/8/25 7/8/25
2.04.0111 Gene Expression Profiling, Protein Biomarkers, and Multimodal Artificial Intelligence for Prostate Cancer Management UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  Title changed with the addition of 3 new indications for the ArteraAI Prostate Test with accompanying evidence. Added NCCN definitions for test in prostate cancer to the rationale section. Multimodal artificial intelligence (MMAI) testing is considered investigational. 9/8/25 7/8/25
2.04.0157 Somatic Biomarker Testing for Immune Checkpoint Inhibitor Therapy (BRAF, MSI/MMR, PD-L1, TMB) UPDATE Clinical evidence to support the policy position reviewed.  Policy extensively pruned: Extensive evidence review is not included for somatic tests of individual genes (not gene panels) associated with FDA-approved therapies with National Comprehensive Cancer Network (NCCN) recommendations of 2A or higher. Policy statement revised to medically necessary for tumor mutational burden testing to select individuals for immune checkpoint inhibitor therapy. 9/8/25 7/8/25
2.04.054 Molecular Genomic Profiling for Cancers of Unknown Primary UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  Title was changed to molecular genomic profiling, and definitions were included for gene expression and comprehensive genomic profiling. Comprehensive genomic profiling added to investigational policy statement. 9/8/25 7/8/25
2.04.087 Genetic Testing for Hereditary Hearing Loss UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  There is no change to the policy position statement listed. 9/8/25 7/8/25
12.01.020 Briumvi, Lemtrada, Ocrevus, Tysabri UPDATE Updated policy information, including updated policy position information. 9/8/25 7/8/25
3.01.003 Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder DELETE Archiving the criteria 8/18/25 6/19/25
12.01.004 Brineura UPDATE Updated policy information, including updated policy position information 8/18/25 6/19/25
12.01.016 IVIG UPDATE Updated policy information, including updated policy position information 8/18/25 6/19/25
12.01.019 Injectable Asthma Agents UPDATE Updated policy information, including updated policy position information 8/18/25 6/19/25
12.01.021 Krystexxa UPDATE Updated policy information, including updated policy position information 8/18/25 6/19/25
12.01.022 Kymriah UPDATE Updated policy information, including updated policy position information 8/18/25 6/19/25
12.01.023 Lysosomal Storage Disorders UPDATE Updated policy information, including updated policy position information 8/18/25 6/19/25
12.01.031 Bevacizumab UPDATE Updated policy information, including updated policy position information 8/18/25 6/19/25
12.01.17 Health Care Provider Administered (HCPA) Biologic Immunomodulator - Actemra® (tocilizumab), Avsola™ (infliximab-axxq), Cimzia® certolizumab pegol), Entyvio (vedolizumab), Ilumya™ (tildrakizumab-asmn), Inflectra® (infliximab-dyyb), Orencia® (abatacept), Remicade®, Infliximab, Renflexis (infliximab-abda), Simponi ARIA® (golimumab), Stelara® (ustekinumab) , Taltz® (ixekizumab) DELETE Archiving the criteria as policy 12.01.018 will replace this policy 8/18/25 6/19/25
12.01.068 Gene Therapies for Sickle Duchenne Muscular Dystrophy – Elevidys DELETE Archiving Policy 8/25/25 6/24/25
12.01.017 Health Care Provider Administered (HCPA) Biologic Immunomodulator - Actemra® (tocilizumab), Avsola™ (infliximab-axxq), Cimzia® certolizumab pegol), Entyvio (vedolizumab), Ilumya™ (tildrakizumab-asmn), Inflectra® (infliximab-dyyb), Orencia® (abatacept), Remicade®, Infliximab, Renflexis (infliximab-abda), Simponi ARIA® (golimumab), Stelara® (ustekinumab) , Taltz® (ixekizumab) DELETE Archiving the criteria. 8/25/25 6/13/25
12.01.018 Infusible Biologic Immunomodulator - Actemra®, Avsola®, Cimzia® , Cosentyx®, Entyvio®, Ilumya®, Inflectra®, Omvoh®, Orencia®, Remicade®, Infliximab, Renflexis®, Simponi ARIA®, Skyrizi®, Stelara®, Taltz®, Tofidence™, Tremfya®, Tyenne® UPDATE Updated policy information, including updated policy position information. 7/1/25 5/1/25
7.01.014 Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures) UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  There is no change to the policy position statement listed. 7/28/25 5/26/25
8.03.001 Functional Neuromuscular Electrical Stimulation UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  There is no change to the policy position statement listed. 7/28/25 5/26/25
8.03.013 Sensory Integration Therapy and Auditory Integration Therapy UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  There is no change to the policy position statement listed. 7/28/25 5/26/25
9.03.001 Keratoprosthesis UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  There is no change to the policy position statement listed. 7/28/25 5/26/25
9.03.008 Photodynamic Therapy for Choroidal Neovascularization UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  There is no change to the policy position statement listed. 7/28/25 5/26/25
9.03.023 Intravitreal and Punctum Corticosteroid Implants UPDATE Clinical evidence to support the policy position reviewed and refereneces added.  There is no change to the policy position statement listed. 7/28/25 5/26/25
12.01.070 Uplizna UPDATE Adding HCPCS code J1823 7/28/25 5/26/25
12.01.011 Exondys DELETE Archiving the criteria. 7/28/25 5/26/25
12.01.015 H.P. Acthar Gel DELETE Archiving the criteria. 7/28/25 5/26/25
5.01.017 Repository Corticotropin Injection NEW Implementation of NEW guidelines. 7/28/25 5/26/25
5.01.027 Treatment for Duchenne Muscular Dystrophy UPDATE Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. 7/28/25 5/26/25
12.01.024 Makena DELETE Archiving the criteria. 7/14/25 5/15/25
2.01.038 Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease UPDATE Clinical evidence to support the policy position reviewed and references added.  One policy statement changed to include an additional device; "Transoral incisionless fundoplication (eg, EsophyX ,MUSE, GERDX) is considered investigational as a treatment of gastroesophageal reflux disease." Overall intent unchanged.  Coding addition of K44.9 for hiatal hernia. 7/7/25 5/1/25
2.01.089 Laser Treatment of Onychomycosis UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.04.007 Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.04.128 Genetic Testing for Fanconi Anemia UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.04.135 Testing Serum Vitamin D Levels UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.04.136 Nutrient/Nutritional Panel Testing UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.04.147 Next-Generation Sequencing for the Assessment of Measurable Residual Disease UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.04.151 Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Breast Cancer (BRCA1, BRCA2, PIK3CA, Ki-67, RET, BRAF, ESR1, NTRK) UPDATE Clinical evidence to support the policy position reviewed and references added. itle changed to include NTRK. Medically necessary policy statement added for NTRK gene fusion testing for individuals with recurrent unresectable (local or regional) or stage IV breast cancer to select individuals for treatment with FDA-approved therapies. Investigational policy statement added for NTRK gene fusion testing in all other situations. All other policy statements unchanged. 7/7/25 5/1/25
2.04.023 Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disorders UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.04.056 Immune Cell Function Assay UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.04.058 Nerve Fiber Density Measurement UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.04.062 Multimarker Serum Testing Related to Ovarian Cancer UPDATE Clinical evidence to support the policy position reviewed.  OvaWatch does not have its own 510K # or FDA approval paperwork yet, but FDA 510(k) submission is planned and in process according to Aspira. Recommend adding when it is cleared. Policy statement unchanged. 7/7/25 5/1/25
2.04.065 Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.04.066 Serum Biomarker Human Epididymis Protein 4 UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 7/7/25 5/1/25
6.01.033 Wireless Capsule Endoscopy for Gastrointestinal Disorders UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 7/7/25 5/1/25
6.01.049 Computed Tomography Perfusion Imaging of the Brain UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 7/7/25 5/1/25
6.01.062 Oncologic Applications of Positron Emission Tomography Scanning (Breast and Gynecologic) UPDATE Clinical evidence to support the policy position reviewed and references added.  New PICO on the use of adjunctive 18F-FES-PET in individuals with recurrent or metastatic breast cancer and in need of estrogen receptor status information to make decisions about endocrine therapy added with an investigational policy statement. All other policy statements unchanged. 7/7/25 5/1/25
7.01.165 Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 7/7/25 5/1/25
7.01.047 Bariatric Surgery UPDATE Clinical evidence to support the policy position reviewed, revisions have been made to the Rationale section and references added.  A new PICO, as well as indications and evidence review for esophagogastroduodenoscopy in the context of bariatric surgery, have been added based on Topic Selection of July 2024 following the introduction of a new CPT Code. An investigational statement concerning the routine use of esophagogastroduodenoscopy during bariatric surgery has also been added. Added the obesity BMI threshold for the Asian population in the Policy Guidelines section. 7/7/25 5/1/25
8.01.016 Chemical Peels UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.01.57 Electrostimulation and Electromagnetic Therapy for Treating Wounds UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.01.68 Laboratory Tests Post Transplant and for Heart Failure UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.04.43 Genetic Testing for Cardiac Ion Channelopathies UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.04.79 Genetic Testing for Alpha-1 Antitrypsin Deficiency UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.04.83 Genetic Testing for FMR1 Variants (Including Fragile X Syndrome) UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 7/7/25 5/1/25
2.04.89 Genetic Testing for FMR1 Variants (Including Fragile X Syndrome) UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 7/7/25 5/1/25
6.01.10 Stereotactic Radiosurgery and Stereotactic Body Radiotherapy UPDATE Clinical evidence to support the policy position reviewed and references added.  New indication added for small cell lung cancer with an investigational policy statement. All other policy statements unchanged. 7/7/25 5/1/25
7.01.153 Stereotactic Radiosurgery and Stereotactic Body Radiotherapy UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 7/7/25 5/1/25
6.01.023 Diagnosis and Treatment of Sacroiliac Joint Pain UPDATE Coding update: added C1737 6/30/25 4/25/25
6.01.061 Oncologic Applications of Positron Emission Tomography Scanning (Gastrointestinal and Pancreatic) UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/30/25 4/25/25
6.01.063 Oncologic Applications of Positron Emission Tomography Scanning (Bone and Sarcoma) UPDATE Clinical evidence to support the policy position reviewed.  Minor editorial refinements to policy statements; intent unchanged. 6/30/25 4/25/25
6.01.064 Oncologic Applications of Positron Emission Tomography Scanning (Hematologic) UPDATE Clinical evidence to support the policy position reviewed.  Policy statements unchanged. Policy guidelines updated to acknowledge situations when there are contraindications to contrast agents, making initial CT scans unattainable. 6/30/25 4/25/25
6.01.065 Oncologic Applications of Positron Emission Tomography Scanning (Lung) UPDATE Clinical evidence to support the policy position reviewed and references added.  Minor editorial refinements made to policy statements; intent unchanged. Policy guidelines updated to acknowledge situations when there are contraindications to contrast agents making initial CT scans unattainable. 6/30/25 4/25/25
6.01.066 Oncologic Applications of Positron Emission Tomography Scanning (Thyroid, Neuroendocrine, Head and Neck) UPDATE Clinical evidence to support the policy position reviewed and references added.  Minor editorial refinements made to policy statements; intent unchanged. Policy guidelines updated to acknowledge situations when there are contraindications to contrast agents making initial CT scans unattainable. 6/30/25 4/25/25
6.01.067 Oncologic Applications of Positron Emission Tomography Scanning (Brain, Melanoma, Unknown Primary) UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/30/25 4/25/25
7.01.112 Transanal Endoscopic Microsurgery UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/30/25 4/25/25
7.01.159 Sphenopalatine Ganglion Block for Headache UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/30/25 4/25/25
9.03.021 Aqueous Shunts and Stents for Glaucoma UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/30/25 4/25/25
2.01.071 Nonpharmacologic Treatment of Rosacea DELETE Archiving the criteria. 6/30/25 4/25/25
2.03.005 Uses of Monoclonal Antibodies for the Treatment of Non-Hodgkin Lymphoma DELETE Archiving the criteria. 6/23/25 4/22/25
15.01.003 Drug Testing in Pain Management and Substance Use Disorder Treatment UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 6/23/25 4/22/25
7.01.123 Plugs for Anal Fistula Repair DELETE Archiving the criteria. 6/23/25 4/22/25
7.01.137 Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease DELETE Archiving the criteria. 6/23/25 4/22/25
5.01.009 Advanced Therapies for Pharmacologic Treatment of Pulmonary Hypertension NEW Implementation of NEW guidelines. 6/23/25 4/22/25
5.01.005 Calcium Sensing Receptor Agonists - Parsabiv NEW Implementation of NEW guidelines. 6/23/25 4/22/25
2.04.125 Proteomic Testing for Targeted Therapy in Non-Small-Cell Lung Cancer UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 6/23/25 4/22/25
2.04.019 Pharmacogenomic and Metabolite Markers for Patients Treated With Thiopurines UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 6/23/25 4/22/25
2.04.033 Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/23/25 4/22/25
2.04.036 Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer UPDATE Clinical evidence to support the policy position reviewed and references added.  New indications and evidence reviews added for the BluePrint and Male Breast Cancer.  There is no change to the policy position statement listed. 6/23/25 4/22/25
2.04.041 Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease NEW Implementation of NEW guidelines. 6/23/25 4/22/25
2.04.045 Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Non-Small-Cell Lung Cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS) UPDATE Coding Change only: 81191-81194 added for NTRK 6/23/25 4/22/25
2.04.084 Measurement of Serum Antibodies to Selected Biologic Agents UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/23/25 4/22/25
2.04.095 Human Leukocyte Antigen Testing for Celiac Disease UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/23/25 4/22/25
2.04.096 Genetic Testing for Statin-Induced Myopathy UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/23/25 4/22/25
8.01.058 Cranial Electrotherapy Stimulation and Auricular Electrostimulation UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/16/25 4/9/25
2.01.050 Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/16/25 4/9/25
2.01.093 Antigen Leukocyte Antibody Test UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 6/16/25 4/9/25
2.04.155 Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 6/16/25 4/9/25
2.04.139 Genetic Testing for Heterozygous Familial Hypercholesterolemia UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 6/16/25 4/9/25
2.04.013 Genetic Testing for Alzheimers Disease UPDATE Coding correction - removed 0016M due to out-of-scope. 6/16/25 4/9/25
2.04.014 Evaluation of Biomarkers for Alzheimer Disease UPDATE Clinical evidence to support the policy position reviewed and references added.  Clinical input added. Policy statements changed to medically necessary specifically for indication related to use of CSF biomarkers to select individuals for treatment with FDA-approved amyloid targeting therapies. Other policy statements remain investigational. 6/16/25 4/9/25
2.04.159 Laboratory Testing Investigational Services UPDATE Coding update only: 0365U revised 1/1/25; 0380U deleted 6/16/25 4/9/25
2.04.052 Molecular Testing for the Management of Pancreatic Cysts and Solid Pancreaticobiliary Lesions UPDATE Clinical evidence to support the policy position reviewed.  he indication and investigational policy statement for topographic genotyping (e.g. BarreGen molecular testing) has been migrated to policy 7.01.167 - Adjunctive Techniques for Screening, Surveillance, and Risk Classification of Barrett Esophagus and Esophageal Dysplasia. Policy statement otherwise unchanged. 6/16/25 4/9/25
2.04.059 Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/16/25 4/9/25
2.04.063 Use of Common Genetic Variants (Single Nucleotide Variants) to Predict Risk of Nonfamilial Breast Cancer UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 6/16/25 4/9/25
2.04.085 BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 6/16/25 4/9/25
2.04.093 Genetic Cancer Susceptibility Panels Using Next Generation Sequencing UPDATE Coding updated: 81435 and 81437 revised; 81433, 81436, 81438 deleted 6/16/25 4/9/25
2.04.097 Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 6/16/25 4/9/25
15.01.002 Applied Behavioiral Analysis Policy UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 6/16/25 4/9/25
2.04.159 Laboratory Testing Investigational Services UPDATE Update to coding only: 0365U revised 1/1/25 and 0380U deleted. 6/9/25 4/3/25
6.01.043 Contrast-Enhanced Computed Tomographic Angiography for Coronary Artery Evaluation UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/9/25 4/3/25
6.01.046 Dynamic Spinal Visualization and Vertebral Motion Analysis UPDATE Clinical evidence to support the policy position reviewed and references added.  Titile updated to include Vertebral Motion Analysis and an investigational policy position statement added. 6/9/25 4/3/25
7.01.158 Balloon Dilation of the Eustachian Tube NEW Implementation of NEW guidelines. 6/9/25 4/3/25
7.01.075 Cryosurgical Ablation of Primary or Metastatic Liver Tumors UPDATE Clinical evidence to support the policy position reviewed, guidelines updated and references added.  There is no change to the policy position statement listed. 6/9/25 4/3/25
6.01.051 Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/9/25 4/3/25
6.01.056 Myocardial Sympathetic Innervation Imaging in Individuals With Heart Failure DELETE Archiving the criteria. 6/9/25 4/3/25
7.01.009 Risk-Reducing Mastectomy DELETE Archiving the criteria. 6/9/25 4/3/25
7.01.141 Lumbar Spinal Fusion DELETE Archiving the criteria. 6/9/25 4/3/25
7.01.152 Magnetic Resonance Imaging-Targeted Biopsy of the Prostate DELETE Archiving the criteria. 6/9/25 4/3/25
7.01.095 Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors UPDATE Coding updated: Added 60660 and 60661 6/9/25 4/3/25
7.03.012 Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes NEW Implementation of NEW guidelines. 6/9/25 4/3/25
8.01.061 Focal Treatments for Prostate Cancer UPDATE Clinical evidence to support the policy position reviewed and references added.  New indication added for irreversible electroporation. Policy statements unchanged. There is no change to the policy position statement listed. 6/9/25 4/3/25
2.01.027 Biofeedback as a Treatment of urinary incontinence in Adults DELETE Archiving the criteria. 6/9/25 4/3/25
2.04.137 Genetic Testing for Neurofibromatosis UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/2/25 3/27/25
2.04.15 Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated With High Bone Turnover UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 6/2/25 3/27/25
2.04.43 Genetic Testing for Cardiac Ion Channelopathies UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/2/25 3/27/25
2.04.79 Genetic Testing for Alpha-1 Antitrypsin Deficiency UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 6/2/25 3/27/25
2.04.83 Genetic Testing for FMR1 Variants (Including Fragile X Syndrome) UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/2/25 3/27/25
2.04.89 Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/2/25 3/27/25
6.01.10 Stereotactic Radiosurgery and Stereotactic Body Radiotherapy UPDATE Clinical evidence to support the policy position reviewed and references added. A new indication added for small cell lung cancer with an investigational policy statement.  6/2/25 3/27/25
7.01.153 Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast NEW Implementation of NEW guidelines. 6/2/25 3/27/25
2.01.004 Hyperbaric Oxygen Therapy UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/2/25 3/27/25
2.04.008 Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes UPDATE Coding updated: 81436 deleted 12/31/24; 81435 revised 1/1/25 6/2/25 3/27/25
2.04.107 Carrier Screening for Genetic Diseases UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/2/25 3/27/25
2.04.111 Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/2/25 3/27/25
2.04.117 Genetic Testing for Mitochondrial Disorders UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 6/2/25 3/27/25
2.04.153 Tumor-Informed Circulating Tumor DNA Testing for Cancer Management UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 6/2/25 3/27/25
5.01.044 Treatment of Congenital Athymia NEW Implementation of NEW guidelines. 6/2/25 3/27/25
6.01.003 Computed Tomography to Detect Coronary Artery Calcification UPDATE Clinical evidence to support the policy position reviewed.  There is no change to the policy position statement listed. 6/2/25 3/27/25
6.01.018 Scintimammography and Gamma Imaging of the Breast and Axilla DELETE Archiving the criteria. 6/2/25 3/27/25
6.01.026 Oncologic Applications of Positron Emission Tomography Scanning (Genitourinary) UPDATE Clinical evidence to support the policy position reviewed, references added and guidelines updaeted.  Medically necessary policy statements on prostate cancer modified to include new agent (flotufolastat-F18). 6/2/25 3/27/25
6.01.032 Virtual Colonoscopy/Computed Tomography Colonography DELETE Archiving the criteria. 6/2/25 3/27/25
6.01.040 Whole Body Dual X-Ray Absorptiometry to Determine Body Composition DELETE Archiving the criteria. 6/2/25 3/27/25
6.01.047 Functional Magnetic Resonance Imaging of the Brain (Title change Functional Magnetic Resonance Imaging of the Brain for Presurgical Mapping or Seizure Focus Location) DELETE Archiving the criteria. 6/2/25 3/27/25
1.01.018 Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers UPDATE Clinical evidence to support the policy position reviewed and references added.  The second PICO (pneumatic compression pumps for lymphedema unresponsive to conservative therapy) has been refined to more accurately frame the intervention under review.  There is no change to the policy position statement listed. 5/26/25 3/20/25
2.01.82 Bioimpedance Devices for Detection and Management of Lymphedema UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 5/26/25 3/20/25
2.04.124 Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 5/26/25 3/20/25
2.04.131 Pharmacogenetic Testing for Pain Management UPDATE Clinical evidence to support the policy position reviewed and references added.  New indication added for individuals with need for pharmacologic management of acute pain who receive pharmacogenetic testing to assess risk of developing opioid use disorder, with an investigational policy statement. Other policy statement unchanged. 5/26/25 3/20/25
17.01.001 Applied Behavioral Analysis (FEP Only) DELETE Criteria is located in policy 15.01.002 5/26/25 3/20/25
2.01.077 Automated Point-of-Care Nerve Conduction Tests DELETE Achiving the criteria. 5/12/25 3/12/25
8.01.15 Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.17 Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.20 Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.21 Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.22 Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.23 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.24 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.25 Hematopoietic Cell Transplantation for Autoimmune Diseases UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.26 Hematopoietic Cell Transplantation for Acute Myeloid Leukemia UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.28 Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.29 Hematopoietic Cell Transplantation for Hodgkin Lymphoma UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.30 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.32 Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.33 High-Dose Rate Temporary Prostate Brachytherapy UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.34 Hematopoietic Cell Transplantation for Solid Tumors of Childhood UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.35 Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.42 Hematopoietic Cell Transplantation for Primary Amyloidosis UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.52 Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow) UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
8.01.55 Stem Cell Therapy for Peripheral Arterial Disease UPDATE Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. 5/12/25 3/12/25
5.01.030 Treatment of Hereditary Transthyretin-Mediated Amyloidosis in Adult Patients - Onpattro, Amvuttra NEW Implementation of NEW guidelines. 5/15/25 2/28/25
12.01.074 Hympavzi Prior Authorization with Quantity Limit NEW Implementation of NEW guidelines 5/1/25 2/28/25
12.01.073 Yorvipath Prior Authorization with Quantity Limit NEW Implementation of NEW guidelines 5/1/25 2/28/25
12.01.072 Niemann-Pick Disease Type C Agents Prior Authorization with Quantity Limit NEW Implementation of NEW guidelines 5/1/25 2/28/25
2.02.001 Catheter Ablation for Cardiac Arrhythmias DELETE Archiving the criteria. 5/1/25 2/27/25
2.01.079 Noncontact Ultrasound Treatment for Wounds DELETE Archiving the criteria. 4/28/25 2/27/25
11.01.154 Chronic Wound Management DELETE Archiving the criteria. 4/28/25 2/27/25
2.04.141 Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) NEW Implementation of NEW guidelines. 4/28/25 2/27/25
2.04.127 Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 4/28/25 2/27/25
2.02.033 Phrenic Nerve Stimulation for Central Sleep Apnea NEW Implementation of NEW guidelines. 4/28/25 2/27/25
5.01.048 Gene Therapies for Sickle Cell Disease - Casgevy, Lyfgenia NEW Implementation of NEW guidelines. 4/28/25 2/27/25
12.01.068 Gene Therapies for Sickle Duchenne Muscular Dystrophy – Elevidys NEW Implementation of NEW guidelines. 4/28/25 2/27/25
5.01.048 Gene Therapies for Sickle Cell Disease - Casgevy, Lyfgenia NEW Implementation of NEW guidelines. 4/8/25 2/7/25
12.01.018 Infusible Biologic Immunomodulators - Actemra, Avsola, Cimzia, Cosentyx, Entyvio, Ilumya, Inflectra, Omvoh, Orencia, Remicade, Infliximab, Renflexis, Simponi Aria, Skyrizi, Stelara, Taltz, Tofidence, Tremfya, Tyenne UPDATE Clinical evidence to support the policy position reviewed and references added. The following medications were removed: Amjevita® (adalimumabatto),  Cyltezo®/Adal imumabadbm, Enbrel® (etanercept), Hadlima™ (adalimumabbwwd), Hulio®, Adalimumabfkjp, Humira® (adalimumab), Hyrimoz®/Ad alimumabadaz, Idacio® (adalimumabaacf), Kevzara® (sarilumab), Kineret® (anakinra), Litfulo™ (ritlecitinib), Olumiant® (baricitinib),Rinvoq™ (upadacitinib extended release), Siliq™ (brodalumab), Sotyktu™ (deucravacitin ib), Xeljanz® (tofacitinib), Xeljanz XR® (tofacitinib extended release) Yuflyma® (adalimumabaaty), Yusimry™ (adalimumabaqvh)The following medications were added with specific criteria for approval updated: Avsola, Ilumya, Inflectra, Omvoh, Remicade, Renflexis, Tofidence, Tremfya, Tyenne. 4/8/25 2/7/25
15.01.004 Basivertebral Nerve Ablation NEW Implementation of NEW guidelines. 4/8/25 2/7/25
7.03.011 Total Artificial Hearts and Implantable Ventricular Assist Devices UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 4/8/25 2/7/25
7.03.013 Composite Tissue Allotransplantation of the Hand and Face UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 4/8/25 2/7/25
8.01.068 Omidubicel as Adjunct Treatment for Hematologic Malignancies UPDATE Clinical evidence to support the policy position reviewed and references added.  Policy statements changed to: Omidubicel is considered medically necessary in individuals 12 years or older with hematologic malignancies planning myeloablative allogenic umbilical cord transplantation to reduce the time to neutrophil recovery and the incidence of infection. Investigational statement added for all other uses. 4/8/25 2/7/25
4.02.005 Preimplantation Genetic Testing NEW Implementation of NEW guidelines. 4/8/25 2/7/25
2.04.141 Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) NEW Implementation of NEW guidelines. 4/8/25 2/7/25
2.04.149 Molecular Testing for Germline Variants Associated with Ovarian Cancer (BRIP1, RAD51C, RAD51D, NBN) NEW Implementation of NEW guidelines. 4/8/25 2/7/25
2.04.154 Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1, CTNNA1) NEW Implementation of NEW guidelines. 4/8/25 2/7/25
4.01.018 Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome NEW Implementation of NEW guidelines. 4/8/25 2/7/25
8.01.008 Intraoperative Radiotherapy DELETE Archiving the criteria. 4/8/25 2/7/25
12.01.016 Immune Globulins UPDATE Biosimilar products of Alyglo, Asceniv, Cutaquig, Panzyga and Xembify were added to the policy.

Effective 2/18/2025, some members may be required to utilize preferred products. The preferred products for Immune Globulins IV are Octagam, Gamunex-C/Gammaked, Gammagard, and Privigen.		 2/18/25 12/20/24
7.01.164 Hydrogel Spacer use During Radiotherapy for Prostate Cancer UPDATE Clinical evidence to support the policy position was updated, new products added to Regulatory Status and references added.   There is no change to the policy position statement listed. 2/18/25 12/20/24
8.01.006 Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus UPDATE Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed. 2/18/25 12/20/24
8.01.013 Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early-Stage Breast Cancer UPDATE Clinical evidence to support the policy position was updated and references added.   There is no change to the policy position statement listed. 2/18/25 12/20/24
8.01.014 Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds UPDATE Clinical evidence to support the policy position reviewed and references added.  There is no change to the policy position statement listed. 2/18/25 12/20/24
12.01.051 Injectable and Implantable Testosterone - Aveed, Delatestryl, Depo-Testosterone DELETE Archiving this criteria - see policy 5.01.023 2/18/25 12/20/24
12.01.031 Bevacizumab UPDATE Biosimilar products of Alymsys, Vegzelma, and Zirabev were added to the policy.

Effective 2/1/2025, some members may be required to utilize preferred products. The preferred products for Bevacuzmab are Zirabev or Mvasi.		 2/1/25 12/1/24
12.01.052 Viscosupplements Medical Drug Criteria UPDATE Biosimilar products of Triluron, TriVisc, Sodium Hyaluronate were added to the policy.

Effective 2/1/2025, some members may be required to utilize preferred products. The preferred products for Viscosupplements are Gel-one or Durolane.		 2/1/25 12/1/24
12.01.017 Health Care Provider Administered (HCPA) Biologic Immunomodulator UPDATE Added preferred products language.
Effective 2/1/2025, some members may be required to utilize preferred products. The preferred products for biologic immunomodulators are Inflectra or Avsola.		 2/1/25 12/1/24
12.01.006 Colony Stimulating Factors - Neupogen, Neulasta, Leukine, Granix, Zarxio UPDATE Biosimilar products of Fylnetra, Rolvedon, Stimufend were added to the policy.

Effective 2/1/2025, some members may be required to utilize preferred products. The preferred products for colony stimulating factors are Neulasta or Udenica.		 2/1/25 12/1/24
12.01.016 Immune Globulins UPDATE Biosimilar products of Alyglo, Asceniv, Cutaquig, Panzyga and Xembify were added to the policy.

Effective 2/1/2025, some members may be required to utilize preferred products. The preferred products for Immune Globulins IV are Octagam, Gamunex-C/Gammaked, Gammagard, and Privigen.		 2/1/25 12/1/24
2.04.150 Serologic Genetic and Molecular Screening for Colorectal Cancer NEW Implementation of NEW guidelines. 1/27/25 11/27/24
1.01.029 Tumor Treating Fields Therapy UPDATE Clinical evidence to support the policy position reviewed. There are minor editorial changes to the policy position statement listed. 1/27/25 11/27/24
1.01.030 Artificial Pancreas Device Systems UPDATE Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. 1/27/25 11/27/24
2.01.073 Actigraphy UPDATE Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. 1/27/25 11/27/24
2.02.030 Transcatheter Mitral Valve Repair or Replacement UPDATE Policy titled changed to include ""replacement"", new indication for transseptal valve-in-valve replacement and references added. Policy statement added: Transcatheter mitral valve-in-valve replacement (TMViVR) with a transcatheter heart valve system approved for use for repair of a degenerated bioprosthetic valve (valve-in-valve) is considered medically necessary for individuals when all of the following conditions are present:
Failure (stenosed, insufficient, or combined) of a surgical bioprosthetic mitral valve; AND New York Heart Association heart failure class II, III, or IV symptoms; AND Individual is not an operable candidate for open surgery, as documented by at least 2 cardiovascular specialists (including a cardiac surgeon); OR individual is an operable candidate but is considered at increased surgical risk for open surgery, as documented by at least 2 cardiac specialists (including a cardiac surgeon); OR individual is considered at increased surgical risk for open surgery (eg, repeat sternotomy) due to a history of congenital vascular anomalies AND/OR has a complex intrathoracic surgical history, as documented by at least 2 cardiovascular specialists (including a cardiac surgeon).		 1/27/25 11/27/24
2.03.007 Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies UPDATE Clinical evidence to support the policy position was updated and references added.   There is no change to the policy position statement listed. 1/27/25 11/27/24
2.04.053 Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Metastatic Colorectal Cancer (KRAS, NRAS, BRAF, and HER2) UPDATE Clinical evidence to support the policy position reviewed, new indications and medically necessary policy position statement for NTRK gene fusion testing to select targeted treatment added. 1/27/25 11/27/24
2.04.101 Genetic Testing for Li-Fraumeni Syndrome UPDATE Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. 1/27/25 11/27/24
2.04.110 Genetic Testing for Diagnosis and Management of Mental Health Conditions UPDATE Clinical evidence to support the policy position was updated and references added.   There is no change to the policy position statement listed. 1/27/25 11/27/24
2.04.121 Miscellaneous Genetic and Molecular Diagnostic Tests UPDATE Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. 1/27/25 11/27/24
2.04.080 Genetic Testing for Hereditary Hemochromatosis UPDATE Minimal clinical evidence reviewed.  There is no change to the policy position statement listed. 1/27/25 11/27/24
02.02.016 Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis DELETE Archiving the criteria. 12/9/24 10/7/24
07.01.128 Bronchial Valves UPDATE Clinical evidence to support the policy position was updated, references added and outdated clinical input was removed.  There is no change to the policy position statement listed. 12/9/24 10/7/24
07.01.071 Lung Volume Reduction Surgery for Severe Emphysema UPDATE Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. 12/9/24 10/7/24
08.01.046 Intensity Modulated Radiotherapy of the Breast and Lung DELETE Archiving the criteria. 12/9/24 10/7/24
08.01.047 Intensity Modulated Radiotherapy of the Prostate DELETE Archiving the criteria. 12/9/24 10/7/24
08.01.048 Intensity Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid DELETE Archiving the criteria. 12/9/24 10/7/24
08.01.049 Intensity Modulated Radiotherapy of the Abdomen and Pelvis DELETE Archiving the criteria. 12/9/24 10/7/24
08.01.059 Intensity Modulated Radiotherapy of the Central Nervous System DELETE Archiving the criteria. 12/9/24 10/7/24
02.01.073 Actigraphy UPDATE Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. 12/9/24 10/7/24
02.04.080 Genetic Testing for Hereditary Hemochromatosis UPDATE Clinical evidence to support the policy position was updated and references added. There is no change to the policy position statement listed. 12/9/24 10/7/24
07.01.147 Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas UPDATE Title changed to "Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas".  Clinical evidence to support the policy position was updated and references added. Codes 64632, 0441T added to authorization requirement.  Intralesional alcohol ablation added to investigational policy statement. 12/9/24 10/7/24
08.01.019 Treatment of Hyperhidrosis UPDATE Clinical evidence to support the policy position was updated and references were added. There is no change to the policy position statement listed. 12/9/24 10/7/24
07.01.047 Bariatric Surgery UPDATE Clerical error omited codes 43771-43773 - these codes were added to the policy. 12/9/24 10/7/24
01.01.023 Transtympanic Micropressure Applications as a Treatment of Meniere's Disease DELETE Archiving the criteria. 12/9/24 10/7/24
02.02.018 Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia DELETE Archiving the criteria. 12/9/24 10/7/24
02.02.006 Enhanced External Counterpulsation DELETE Archiving the criteria. 12/9/24 10/7/24
02.04.037 Detection of Circulating Tumor Cells in the Management of Patients With Cancer DELETE Archiving the criteria. 12/9/24 10/7/24
02.04.081 Genetic Testing for Rett Syndrome DELETE Archiving the criteria. 12/9/24 10/7/24
02.04.067 KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy DELETE Archiving the criteria. 12/9/24 10/7/24
02.04.076 Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers DELETE Archiving the criteria. 12/9/24 10/7/24
02.04.059 Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies UPDATE Clinical evidence to support the policy position was updated, code 0243U was added and code 0318U was removed. There is no change to the policy position statement listed. 12/9/24 10/7/24
02.01.001 Diagnosis and Management of Idiopathic Environmental Intolerance (ie, Multiple Chemical Sensitivities) DELETE Archiving the criteria. 12/9/24 10/7/24
07.01.018 Automated Percutaneous and Percutaneous Endoscopic Discectomy NEW Implementation of NEW guidelines. 12/9/24 10/7/24
08.01.022 Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias DELETE Archiving the criteria. 12/9/24 10/7/24
11.01.147 Hematopoetic Stem Cell Transplantation for Breast Cancer DELETE Archiving the criteria. 12/9/24 10/7/24
11.01.102 Laminectomy DELETE Archiving the criteria and creating new policy guidelines under policy 07.01.145. 12/9/24 10/7/24
07.01.145 Laminectomy NEW Implementation of NEW guidelines. 12/9/24 10/7/24
11.01.117 Hugh Resolution Anoscopy DELETE Archiving the criteria. 12/9/24 10/7/24
11.01.084 Percutaneous Discectomy DELETE Archiving the criteria. 12/9/24 10/7/24
02.02.018 Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia DELETE Archiving the criteria. 12/9/24 10/7/24
12.01.060 Amtagvi® (lifileucel) (Intravenous) NEW Implementation of NEW guidelines. 12/9/24 10/7/24
06.01.050 Magnetic Resonance Imaging to Monitor the Integrity of Silicone Gel-Filled Breast Implants DELETE Archiving the criteria. 12/9/24 10/7/24
02.04.094 Genetic Testing for Lactase Insufficiency DELETE Archiving the criteria. 12/9/24 10/7/24
06.01.052 Positron Emission Mammography DELETE Archiving the criteria. 12/9/24 10/7/24
02.04.130 Molecular Testing for Chronic Heart Failure and Heart Transplant DELETE Archiving the criteria. 12/9/24 10/7/24
02.01.068 Laboratory Tests Post Transplant and for Heart Failure UPDATE Clinical evidence to support the policy position was updated and code 0085T was removed. New investigational policy statements regarding dd-cfDNA testing in lung and heart transplantation were added. Investigational policy statement for GEP testing (ie, AlloMap) in heart transplantation was updated to include use alone or in combination with dd-cfDNA testing (ie, HeartCare). 12/9/24 10/7/24
07.01.041 Implantable Infusion Pump for Pain and Spasticity DELETE Archiving the criteria. 12/9/24 10/7/24
06.01.037 Radioimmunoscintigraphy (Monoclonal Antibody Imaging) With Indium 111 Capromab Pendetide for Prostate Cancer DELETE Archiving the criteria. 12/9/24 10/7/24
01.01.024 Interferential Current Stimulation UPDATE Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. 12/9/24 10/7/24
02.01.039 Quantitative Sensory Testing UPDATE Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. 12/9/24 10/7/24
02.01.056 Low Level Laser Therapy UPDATE Clinical evidence to support the policy position was updated and code 97037 was added. There is no change to the policy position statement listed. 12/9/24 10/7/24
02.01.061 Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders UPDATE Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. 12/9/24 10/7/24
02.01.096 Autonomic Nervous System Testing UPDATE Clinical evidence to support the policy position was updates & references added. There is no change to the policy position statement listed. 12/9/24 10/7/24
05.01.043 Therapeutic Radiopharmaceuticals for Prostate Cancer NEW Implementation of NEW guidelines. 12/9/24 10/7/24
01.01.023 Transtympanic Micropressure Applications as a Treatment of Meniere's Disease DELETE Archiving the criteria. 12/9/24 10/7/24
02.01.058 Transanal Radiofrequency Treatment of Fecal Incontinence DELETE Archiving the criteria. 12/9/24 10/7/24
02.02.006 Enhanced External Counterpulsation DELETE Archiving the criteria. 12/9/24 10/7/24
02.04.113 Analysis of MGMT Promoter Methylation in Malignant Gliomas DELETE Archiving the criteria. 12/9/24 10/7/24
07.01.079 Whole Gland Cryoablation of Prostate Cancer DELETE Archiving the criteria. 12/9/24 10/7/24
07.01.081 Nerve Graft with Radical Prostatectomy DELETE Archiving the criteria. 12/9/24 10/7/24
07.01.124 Treatment of Varicose Veins/Venous Insufficiency UPDATE Clinical evidence to support the policy position was updates & references added. Minor editorial refinements to policy statement; intent unchanged. 12/9/24 10/7/24
07.01.164 Hydrogel Spacer use During Radiotherapy for Prostate Cancer NEW Implementation of NEW guidelines. 12/9/24 10/7/24
11.01.153 Treatment of Prostate DELETE Archiving the criteria. 12/9/24 10/7/24
06.01.023 Diagnosis and Treatment of Sacroiliac Joint Pain UPDATE Clinical evidence to support the policy position was updated, references added, Codes 0775T and 0809T were deleted effective 12/31/2023 and code 27278 was added effective 01/01/2024. Minor editorial refinements to policy statement; intent unchanged. 12/9/24 10/7/24
01.01.002 Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure DELETE Archiving the criteria. 12/9/24 10/7/24
02.02.024 Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting UPDATE Clinical evidence to support the policy position was updated, references added and code 81418 added. There is no change to the policy position statement listed. 12/9/24 10/7/24
02.04.010 Identification of Microorganisms Using Nucleic Acid Probes UPDATE Clinical evidence to support the policy position was updated, references added and codes 87154, 0301U, 0302U, 87468, 87469, 87484, 0097U, 0151U were removed.  Mycoplasma genitalium added to list of medically necessary NAATs. 12/9/24 10/7/24
02.04.038 Cytochrome P450 Genotype-Guided Treatment Strategy UPDATE Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. 12/9/24 10/7/24
02.04.048 Genotype-Guided Warfarin Dosing UPDATE Clinical evidence to support the policy position was updated. Minor editorial refinements to policy statement; intent unchanged. 12/9/24 10/7/24
02.04.104 Genetic Testing for α-Thalassemia UPDATE Clinical evidence to support the policy position was updated and references added. Corrected third policy statement, intent unchanged: Preconception (carrier) testing for α-thalassemia in prospective parents may be considered medically necessary when both parents have evidence of possible α-thalassemia (including α-thalassemia minor, hemoglobin H disease [α-thalassemia intermedia], or α-thalassemia minima [silent carrier] based on biochemical testing 12/9/24 10/7/24
02.04.119 Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis UPDATE Clinical evidence to support the policy position was updated and code 83529 was added. There is no change to the policy position statement listed. 12/9/24 10/7/24
02.04.123 Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases UPDATE Clinical evidence to support the policy position was updated, references added and code 0312U was added. There is no change to the policy position statement listed. 12/9/24 10/7/24
02.04.140 Genetic Testing for a-Thalassemia UPDATE Clinical evidence to support the policy position was updates. Minor editorial refinements to policy statement; intent unchanged. 12/9/24 10/7/24
07.01.122 Electromagnetic Navigational Bronchoscopy UPDATE Clinical evidence to support the policy position was updated and codes C7509, C7510, C7511 were added. There is no change to the policy position statement listed. 12/9/24 10/7/24
07.01.018 Automated Percutaneous and Percutaneous Endoscopic Discectomy UPDATE Clinical evidence to support the policy position was updated and references added. Minor editorial refinements to policy statement; intent unchanged. 12/9/24 10/7/24
07.01.131 Transcatheter Pulmonary Valve Implantation UPDATE Clinical evidence to support the policy position was updated. Minor editorial refinements to policy statement; intent unchanged. 12/9/24 10/7/24
12.01.067 Leqembi (Lecanemab) NEW Implementation of NEW guidelines. 11/7/24 1/6/25
12.01.060 Amtagvi (lifileucel)(Intravenous) NEW Implementation of New guidelines regarding new to market pharmaceutical Amtagvi. 10/8/24 8/9/24
15.01.001 Wearable Cardioverter Defibrillators NEW Implementation of NEW guidelines. 9/30/24 7/30/24
02.01.058 Transanal Radiofrequency Treatment of Fecal Incontinence DELETE Archiving the criteria. 9/30/24 7/30/24
11.01.014 Intraperitoneal Chemotherapy DELETE Archiving the criteria. 9/30/24 7/30/24
11.01.017 Long QT Syndrome Testing DELETE Archiving the criteria. 9/30/24 7/30/24
11.01.044 Implantable Hormone Replacement Pellets DELETE Archiving the criteria. 9/30/24 7/30/24
11.01.065 Photodynamic Therapy (PDT) with Porifmer Sodium DELETE Archiving the criteria. 9/30/24 7/30/24
11.01.082 Implantable Automatic Cardioverter-Defibrillator DELETE Archiving the criteria. 9/30/24 7/30/24
11.01.088 Transcutaneous Magnetic Stimulation (TMS) DELETE Archiving the criteria. 9/30/24 7/30/24
11.01.099 Islet Cell Transplantation DELETE Archiving the criteria. 9/30/24 7/30/24
11.01.102 Laminectomy DELETE Archiving the criteria. 9/30/24 7/30/24
11.01.121 Single Photon Emission Computed Tomography (SPECT) DELETE Archiving the criteria. 9/30/24 7/30/24
8.03.010 Cognitive Rehabilitation NEW Cognitive Rehabilitation will now be managed through prior authorization. 9/22/24 7/22/24
06.01.055 Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease UPDATE Policy Title Changed; Clinical criteria updated to discuss requirements to ensure appropriate use for Alzheimer's Disease as well as FDG-PET criteria. 9/22/24 7/22/24
11.01.117 High Resolution Anoscopy DELETE No authorization will be required. 9/22/24 7/22/24
6.01.026 Oncologic Applications of Positron Emission Tomography Scanning (Geniourinary) UPDATE Policy Title Changed; Clinical criteria updated for geniourinary oncolgic conditions and removal of all other oncologic indications. Other indications are listed in other policies. 9/22/24 7/22/24
15.01.002 Applied Behavioral Analysis NEW Implementation of public facing guidelines for Applied Behavioral Analysis. BCBSWY has historically held prior authorization requirements for these services. 9/22/24 7/22/24
06.01.067 Oncologic Applications of Positron Emission Tomography Scanning (Brain, Melanoma, Unknown Primary) NEW Implementation of NEW guidelines. 9/22/24 7/22/24
06.01.066 Oncologic Applications of Positron Emission Tomography Scanning (Thyroid, Neuroendocrine, Head and Neck) NEW Implementation of NEW guidelines. 9/22/24 7/22/24
06.01.064 Oncologic Applications of Positron Emission Tomography Scanning (Hematologic) NEW Implementation of NEW guidelines. 9/22/24 7/22/24
06.01.063 Oncologic Applications of Positron Emission Tomography Scanning (Bone and Sarcoma) NEW Implementation of NEW guidelines. 9/22/24 7/22/24
06.01.062 Oncologic Applications of Positron Emission Tomography Scanning (Breast and Gynecologic) NEW Implementation of NEW guidelines. 9/22/24 7/22/24
06.01.061 Oncologic Applications of Positron Emission Tomography Scanning (Gastrointestinal and Pancreatic) NEW Implementation of NEW guidelines. 9/22/24 7/22/24
06.01.051 Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment NEW Implementation of NEW guidelines. 9/22/24 7/22/24
07.01.044 Implantable Cardioverter Defibrillators NEW Implementation of NEW guidelines. 9/22/24 7/22/24
06.01.065 Oncologic Applications of Positron Emission Tomography Scanning (Lung) NEW Implementation of NEW guidelines. 9/22/24 7/22/24
06.01.006 Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography NEW Implementation of NEW guidelines. 9/22/24 7/22/24
15.01.001 Wearable Cardioverter Defibrillators NEW Implementation of NEW guidelines. 9/22/24 7/22/24
02.02.015 Wearable Cardioverter Defibrillators DELETE Archiving the criteria and replacing with NEW policy 15.01.001 9/22/24 7/22/24
06.01.020 Cardiac Applications of Positron Emission Tomography Scanning NEW Implementation of NEW guidelines. 9/22/24 7/22/24
12.01.020 Briumvi, Lemtrada, Ocrevus, Tysabri NEW Implementation of public facing guidelines for Briumvi, Lemtrada, Ocrevus, and Tysabri. BCBSWY has historically held prior authorization requirements for these medications but the criteria was furnished by our Pharmacy Benefit Manager and was cumbersome for providers to access. This is a posting of the criteria set. Please note that authorizations are subject to a one year authorization period while units approved will be subject to standard dosing and quantity level limits. 9/15/24 7/15/24
12.01.059 Verkazia NEW Implementation of NEW guidelines regarding the use of Verkazia. This has historically held prior authorization requirements but was included with other pharmaceuticals for criteria [Ophthalmic Immunomodulators]. This new criteria allows for medication specific guidelines to ensure clear presentation of requirements. 9/15/24 7/15/24
12.01.057 Filsuvez NEW Implementation of NEW guidelines regarding the use of Verkazia. This is a new to market product. 9/15/24 7/15/24
12.01.058 Vyepti NEW Implementation of public facing guidelines for Vyepti. BCBSWY has historically held prior authorization requirements for this medication but the criteria was furnished by our Pharmacy Benefit Manager and was cumbersome for providers to access. This is a posting of the criteria set. 9/15/24 7/15/24

ASC Reimbursement Update

ASC Reimbursement Update

Blue Cross Blue Shield of Wyoming is committed to providing you with updates on upcoming policy and reimbursement changes. Effective, 9/1/24, BCBSWY is updating our ASC rates and rules. ASC rates can be found in the Availity portal under the BCBSWY payer space.

BCBSWY Prior Authorization Webinars

We encourage you to register for an upcoming webinar that is specific to the changes we’re implementing starting July 1 for how we notify you of medical policy updates and transfer prior authorization requests. These new processes are intended to ease the administrative burdens for providers and members for prior authorization requests as required by the recent state legislation, HB0014 Ensuring Transparency in Prior Authorization Act.

We are offering two options that will cover the same content in both sessions and registration is required.

Prior Authorization Enhancements Webinar

Wed., 6/12 12:00-1:00 pm

Register Now

Prior Authorization Enhancements Webinar

Tues., 6/18, 12:00-1:00 pm

Register Now

Medical Policy Update

Prior Authorization Submission Reminder

BCBSWY is committed to improving communication and knowledge of medical policy updates. Effective 9/1/2024, BCBSWY will implement a new medical policy specific to Home Infusion services. Please review the below information for an overview of this policy.

Definition

Home infusion is the administration of medications or nutrition intravenously in a patient’s home or office. Home infusion services must be ordered in writing by a physician.

Documentation must identify and describe the services performed including total time of the service. Appeals submitted without this documentation will be rejected.

Payment for HIT Services

The HCPCS “G” codes for home infusion services are to be used for billing. Billing for “G” codes includes professional services, including nursing services, furnished in accordance with care coordination, patient training and education, remote monitoring, and monitoring services for the provision of home infusion therapy.

Infusion pumps, home infusion drugs, other supplies, are to be billed separately. A G-code is billed for each day that a patient receives an infusion and services are rendered in person from the provider.

Home infusion therapy (HIT) is billed based upon type:

  • Intravenous infusion
  • Subcutaneous infusion
  • Intravenous chemotherapy or complex drug.

Billing for each code type is differentiated based upon “first visit” status. A visit is considered a first visit when it has been at least 60 days since a patient has received any home infusion therapy services billed with a G code.

All HIT services require at least one non-oral drug or biological to be billed alongside the G code. This drug determines the type mentioned above.

Code Description Visit Type
G0068 Administration of Intravenous infusion drug in home General Visit
G0069 Administration of Subcutaneous infusion drug in home
G0070 Administration of Intravenous chemotherapy or other complex drug in home
G0088 Administration of Intravenous infusion drug in home 1st Visit
G0089 Administration of Subcutaneous infusion drug in home
G0090 Administration of Intravenous chemotherapy or other complex drug in home

Services billed with G-codes will only be reimbursable when services are rendered in person in the patient’s home. Provision of medications and remote support alone is not sufficient for a provider to be eligible for HIT reimbursement.

Other HIT Services with Different Guidelines from the Above

Enteral and Parenteral Nutrition Infusions

The HCPCS “S” codes for enteral and parenteral nutrition home infusion services are based on a “per diem” reimbursement methodology (S9341 – S9343, S9364 – S9368). The per diem includes all supplies, care coordination and professional pharmacy services. The per diem code is billed for each day that a patient receives an infusion, and services are rendered in person from the provider. Other nursing services and drug products are billed separately from the per diem.

Reimbursement is allowed separately for the following supplies: ambulatory infusion pumps (E0779-E0781). BCBSWY may allow separate reimbursement for other supplies on a case-by-case basis.

Per diems will only be reimbursable when services are rendered in person in the patient’s home. Provision of medications and remote support alone is not sufficient for a provider to be eligible for per diem reimbursement.

Catheter Care

Bill catheter care per diems (S5497, S5498, S5501, S5502) when provided as a stand-alone therapy. Insertion by a nurse of a PICC line (S5522) or midline (S5523) is coded separately from the other nursing visit codes and per diems. Supplies required from non-routine catheter procedures such as de-clotting supplies (S5517), repair kits (S5518), PICC insertion supplies (S5520) and midline insertion supplies (S5521) are coded separately.

Hydration Therapy

Bill hydration therapy per diems (S9373-S9377) when provided as a stand-alone therapy.

Other Payments

Providers who do not render in-person infusions and are not eligible to be reimbursed a per diem or “G” code may still be eligible to be reimbursed for supplies as detailed below.

Medical Supplies

Medical supplies that are consumable, expendable, disposable, or non-durable and that are used for treatment of a patient’s specific illness, injury, may be reimbursed separately using the appropriate HCPCS code.

Drugs

Drugs should be billed with a HCPCS or CPT code. If a specific code is not available, providers should use J3490, J3590, J7799, or J9999 along with narrative, NDC number, dosage and units supplied. Related NDC codes for compounded products are itemized using the LIN and CTP segments on the 837P claim format. These claims may require manual review.

Multiple Therapies

If multiple therapies that would be billed using a per diem S code are done on the same date of service, append the following modifiers to the per diem S codes:

  • SH – Second concurrently administered infusion therapy
  • SJ – Third or more concurrently administered therapy

Only one G code is reimbursable each day. If two or more home infusion drugs or biologicals from two (or more) different payment categories are administered to an individual concurrently on a single infusion calendar day, one payment.

If both a service billed using a per diem and service billed using a G code are performed on the same day both codes should be submitted. Payment will only be made for the G code.

Claim Form

Home Infusion Therapy (HIT) providers should submit claims for services on HCFA 1500 or 837p.

Stay Informed: Register below for an upcoming prior authorization webinar to learn how BCBSWY will communicate new medical policies and updates beginning 7/1/24.

BCBSWY Prior Authorization Webinars

BCBSWY supported the recent legislation, HB0014 Ensuring Transparency in Prior Authorization Act, and worked with stakeholders to adopt policies intended to ease the administrative burdens for providers and members for prior authorization requests.

These upcoming webinars will help you become familiar with new processes to ease your prior authorization requests. We are offering two options that will cover the same content in both sessions.

Prior Authorization Enhancements Webinar

Wed., 6/12 12:00-1:00 pm

Register Now

Prior Authorization Enhancements Webinar

Tues., 6/18 12:00-1:00 pm

Register Now

Blue Cross Blue Shield of Wyoming will be closed on Monday, May 27 in observance of Memorial Day. Regular business hours will resume on Tuesday, May 28.

Reimbursement Update May 16-2024

Prior Authorization Submission Reminder

Providers should be using the online prior authorization submission portal in Availity. It is now live and fully accessible.

To report any issues related to errors during submission, please call 1-888-666-5188. Our Provider Relations Team will ask you to collect a screenshot of the error including the web address bar and the clock in the bottom right-hand corner of your screen. They will provide you an email address for submission. This will allow our technical teams to validate the issue. Your feedback is critical as we make technical improvements and streamline this process.

Currently, BCBSWY will only accept faxed authorizations for the following:

· FEP Membership (Contract number has an alpha prefix of “R”)

· Residential Treatment Center

· Skilled Nursing Facilities

· Acute Rehabilitation Facilities

· Long Term Acute Care Facilities

· Swing Bed

· Transplant Authorizations

In an effort to prepare for implementation of the 7/1 Prior Authorization Wyoming state legislation, BCBSWY will start requiring the following authorizations to be submitted through Availity effective 6/1/24.

· Residential Treatment Center

· Skilled Nursing Facilities

· Acute Rehabilitation Facilities

· Long Term Acute Care Facilities

· Swing Bed

Sign up for one of our upcoming webinars below to learn more!

BCBSWY Prior Authorization Enhancements

BCBSWY supported the recent legislation, HB0014 Ensuring Transparency in Prior Authorization Act, and worked with stakeholders to adopt policies intended to ease the administrative burdens for providers and members for prior authorization requests.

These upcoming webinars will help you become familiar with new processes to ease your prior authorization requests. We are offering two options that will cover the same content in both sessions.

Prior Authorization Enhancements Webinar

Wed., 6/12 12:00-1:00 pm

Register Now

Prior Authorization Enhancements Webinar

Tues., 6/18 12:00-1:00 pm

Register Now

 

Reimbursement Update

Reimbursement Update

Effective August 1, 2024, Blue Cross Blue Shield of Wyoming will be implementing new rates for all radiology services to align with the Resource-Based Relative Value Scale (RBRVS) payment system.

Rates for individual codes may increase or decrease as we work to make them consistent with the RBRVS. Overall, we estimate that adjusting rates to the RBRVS for these services will result in a net neutral reimbursement change.

Upcoming Provider Webinars

As part of Blue Cross Blue Shield of Wyoming’s ongoing commitment to improve the prior authorization process, we are offering three educational webinars to assist our provider community.

The first webinar will include more helpful tips regarding Predictal and the prior authorization submission process in addition to a question-and-answer portion to help providers improve their understanding of this tool.

Register Now

BCBSWY Prior Authorization Enhancements

BCBSWY supported the recent legislation, HB0014 Ensuring Transparency in Prior Authorization Act, and worked with stakeholders to adopt policies intended to ease the administrative burdens for providers and members for prior authorization requests.

These upcoming webinars will help you become familiar with new processes to ease your prior authorization requests. We are offering two options that will cover the same content in both sessions.

Prior Authorization Enhancements Webinar
Wed., 6/12 12:00-1:00 pm

Register Now

 

Prior Authorization Enhancements Webinar
Tues., 6/18 12:00-1:00 pm

Register Now

Upcoming Provider Webinars

Upcoming Provider Webinars

As part of Blue Cross Blue Shield of Wyoming’s ongoing commitment to improve the prior authorization process, we are offering three educational webinars to assist our provider community.

The first webinar will include more helpful tips regarding Predictal and the prior authorization submission process in addition to a question-and-answer portion to help providers improve their understanding of this tool.

Our Provider Relations Team will ask you to collect a screenshot of the error including the web address bar and the clock in the bottom right-hand corner of your screen. They will provide you an email address for submission. This will help our technical team to validate the issue.

Predictal Webinar

Wed., 5/15 12:00-1:00 pm

Register Now

BCBSWY Prior Authorization Enhancements

BCBSWY supported the recent legislation, HB0014 Ensuring Transparency in Prior Authorization Act, and worked with stakeholders to adopt policies intended to ease the administrative burdens for providers and members for prior authorization requests.

These upcoming webinars will help you become familiar with new processes to ease your prior authorization requests. We are offering two options that will cover the same content in both sessions.

Prior Authorization Enhancements Webinar

Wed., 6/12 12:00-1:00 pm

Register Now

Prior Authorization Enhancements Webinar

Tues., 6/18 12:00-1:00 pm

Register Now

Prior Authorization Procedure Update

Beginning 5/6/24, BCBSWY will no longer require prior authorization on the following cardiac ablation procedures:
CPT CODE: 93613, 93655, 93656, 93657, 93662, 33250, 33521, 33261, C1730, C1731, C1732, C1733, C1759, C1766, C1887, C1892, C1893, C2630
However, BCBSWY will continue to require authorization on cardiac ablation with reconstruction of the atria (i.e. MAZE or modified MAZE procedures).

 

Prior Authorization Portal Update

Announcements

Prior Authorization Portal Update

Providers should begin using the online prior authorization submission portal in Availity. It is now live and fully accessible.

If you encounter any issues, please don’t hesitate to reach out to our Provider Relations team for assistance. We appreciate our Providers who have been able to
provide helpful feedback during this time.

Effective 4/29/2024, BCBSWY will resume not accepting faxed authorizations except for the following:

  • FEP Membership (Contract number has an alpha prefix of “R”)
  • Residential Treatment Center
  • Skilled Nursing Facilities
  • Acute Rehabilitation Facilities
  • Long Term Acute Care Facilities
  • Swing Bed
  • Transplant Authorizations

To report any issues related to errors during submission, please call 1-888-666-5188.

Our Provider Relations Team will ask you to collect a screenshot of the error including the web address bar and the clock in the bottom right-hand corner of your screen. They will provide you an email address for submission. This will help our technical team to validate the issue.

Need Help? Please visit our website for submission instructions here.

Good Habits

Provider Directory Validation Reminder

You can find the Provider Directory Validation guide under the Provider Resources section on the right rail of the website.

Providers can use the Directory Validation tool on the Availity Portal to find NPI and tax ID combinations.

The No Surprises Act (NSA) requires you confirm this information every 90 days.

Confirm Today

Provider Directory Validation Tool Reminder
Provider Resources: Availity Directory Validation Training Guide

Concurrent Review Video

Announcements

Concurrent Review Video

We have recently created a video to help you easily navigate the concurrent review process on Availity.

As a reminder, we also have other in-depth training on various Prior Authorization topics. Please click the button below to view them now.

Prior Authorization Videos

Good Habits

Provider Directory Validation Tool Reminder

You can find the Provider Directory Validation guide under the Provider Resources section on the right rail of the website.

Providers can use the Directory Validation tool on the Availity Portal to find NPI and tax ID combinations.

The No Surprises Act (NSA) requires you confirm this information every 90 days.

Confirm Today

Provider Directory Validation Tool Reminder
Provider Resources: Availity Directory Validation Training Guide

Availity Is The Place for Authorization Submissions

As a reminder, authorizations should be submitted through Availity.

BCBSWY will no longer accept voicemail, mail, or faxed submissions for authorization requests except for the following items:

  • Any FEP authorization not accepted in Availity.
  • Any authorization triggering an error in Availity that has been reported to Provider Relations by calling 1-888-666-5188.
  • Any authorization for transplant services.
  • Any authorization for our pharmacy team.

All authorizations must be submitted through Availity.

Visit Availity!

Tips: CPT Code 83036 Billing

Reminder

CPT Code 83036 Billing Tips

As a reminder, Providers should include category II codes when billing CPT code 83036. Claims without the category II codes billed using CPT code 83036 will be denied. They will need to be resubmitted as a corrected claim.

Please use the codes below now to ensure proper categorization.

CPT 83036 for a HbA1c laboratory test will need the appropriate Category II code on the same claim.

CAT II codes are an informational code and should be billed with either a $0.00 charge or a $0.01 charge if required by your system or clearing house.

CAT II codes are for diagnostic/screening processes or results.

Category II Codes for HgbA1c

Code Usage
3044F-HbA1c —– Less than 7.0%
3051F-HbA1c —– Greater than or equal to 7.0% and less than 8.0%
3052F-HbA1c —– Greater than or equal to 8.0% and less than 9.0%
3046F-HbA1c —– Greater than 9.0%

Claim Adjustment Form

Good Habits

Provider Directory Validation Tool Reminder

You can find the Provider Directory Validation guide under the Provider Resources section on the right rail of the website.

Providers can use the Directory Validation tool on the Availity Portal to find NPI and tax ID combinations.

The No Surprises Act (NSA) requires you confirm this information every 90 days.

Confirm Today

Provider Directory Validation Tool Reminder
Provider Resources: Availity Directory Validation Training Guide

Availity Is The Place for Authorization Submissions

As a reminder, authorizations should be submitted through Availity.

BCBSWY will no longer accept voicemail, mail, or faxed submissions for authorization requests except for the following items:

  • Any FEP authorization not accepted in Availity.
  • Any authorization triggering an error in Availity that has been reported to Provider Relations by calling 1-888-666-5188.
  • Any authorization for transplant services.
  • Any authorization for our pharmacy team.

All authorizations must be submitted through Availity.

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