Administrative bulletin: 2026-01-003 Medical policies

Date: January 1, 2026

Effective date: March 1, 2026 (unless otherwise indicated)

Topics covered in this Administrative Bulletin are applicable to:

Professional and Facility Providers

Professional and facility providers

Notification of new and revised medical policies and preauthorization requirements

Capital Blue Cross has updated Medical Policies as outlined below. Full details on these policy changes are available for review via the Draft Medical Policies page in the Provider Library. Although highlights are noted, please refer to the draft policies for updated criteria and related coding. Administrative changes to policy verbiage have also been made (e.g., changing “members” to “individuals”). These revisions do not change policy intent.

Capital’s medical policies do not constitute medical advice and are not intended to govern the practice of medicine. Coverage for services may vary based on the terms of the member’s benefit booklet and any applicable federal or state laws. In the event an applicable law/regulation supersedes a medical policy, such law/regulation will control.

Where to find policies and codes requiring authorization

From the “Preauthorization and policies” section of the Provider Library, click the “Draft policies” link under the “Medical policies” heading.

To access medical injectable policies, visit Prime Therapeutics.

Codes that require preauthorization are maintained on the Capital Blue Cross Single Source Preauthorization List provider web page.

Medical specialty injectable policies updates

Capital Blue Cross has delegated Medical Specialty Injectable Policies to Prime Medical Pharmacy Solutions (MPS). Prime MPS is updating medical specialty policies (Commercial only) to be more medication-specific. There will be changes in the appearance and formatting of the policies, as well as updated clinical criteria.

If Prior Authorization is required, submit your request online via the Prime MPS GatewayPA Portal. For urgent or expedited requests, call Prime using the phone number below.

If preauthorization cannot be performed online, Prime MPS will be accepting requests via phone or fax:

For further details on Medical Injectable policies (Commercial Only), please follow these instructions:

  • Access the Prime MPS GatewayPA Portal at http://www.GatewayPA.com.
  • Click on “Capital Blue Cross” under “Clinical Guidelines” on the left side of the screen to view medical policies.

To be consistent with clinical monitoring, prior authorization periods for some drugs have changed. Please see the individual drug medical policy for the length of authorization.

Policy name
Action
Effective date
Highlights

Keytruda Qlex™

New

3/1/2026

J9999 will now require PA for new drug Keytruda Qlex

Grafapex™

New

3/1/2026

J0614 will now require PA for new drug Grafapex

Aflibercept

Revised

3/1/2026
  • J3590 will now require PA for new biosimilar, Eydenzelt
  • See updated policy for details.

Denosumab

Revised

3/1/2026
  • J3590 will now require PA for new denosumab biosimilars Bildyos, Bosaya, Enoby, Aukelso, Bilprevda, and Xtrenbo
  • Q5157 will now require PA for new unbranded biosimilar, Denosumab-bmwo
  • See updated policy for details.

IVIG

Revised

3/1/2026
  • J1599 will now require PA for new product Qivigy
  • See updated policy for details.

Ustekinumab

Revised

3/1/2026
  • Q5137 will now require PA for unbranded Ustekinumab-auub
  • See updated policy for details.

Abecma®

Revised

3/1/2026

See updated policy for details.

Adcetris®

Revised

3/1/2026

See updated policy for details.

Aucatzyl®

Revised

3/1/2026

See updated policy for details.

Breyanzi®

Revised

3/1/2026

See updated policy for details.

Carvykti®

Revised

3/1/2026

See updated policy for details.

Darzalex® IV

Revised

3/1/2026

See updated policy for details.

Erbitux®

Revised

3/1/2026

See updated policy for details.

Evkeeza®

Revised

3/1/2026

See updated policy for details.

Long-acting granulocyte colony stimulating factors

Revised

3/1/2026

See updated policy for details.

Short-acting granulocyte colony stimulating factors

Revised

3/1/2026

See updated policy for details.

Keytruda® IV

Revised

3/1/2026

See updated policy for details.

Kimmtrak®

Revised

3/1/2026

See updated policy for details.

Kisunla™

Revised

3/1/2026

See updated policy for details.

Krystexxa®

Revised

3/1/2026

See updated policy for details.

Kymriah™

Revised

3/1/2026

See updated policy for details.

Lanreotide

Revised

3/1/2026

See updated policy for details.

Libtayo®

Revised

3/1/2026

See updated policy for details.

Leukine®

Revised

3/1/2026

See updated policy for details.

Niktimvo™

Revised

3/1/2026

See updated policy for details.

Ryoncil®

Revised

3/1/2026

See updated policy for details.

Rytelo™

Revised

3/1/2026

See updated policy for details.

Sandostatin® LAR

Revised

3/1/2026

See updated policy for details.

Signifor® LAR

Revised

3/1/2026

See updated policy for details.

Tecartus®

Revised

3/1/2026

See updated policy for details.

Tecentriq® IV

Revised

3/1/2026

See updated policy for details.

Tecentriq™ SQ

Revised

3/1/2026

See updated policy for details.

Yescarta®

Revised

3/1/2026

See updated policy for details.

Zepzelca®

Revised

3/1/2026

See updated policy for details.

Fasenra®

Revised

3/1/2026

See updated policy for details.

Nucala®

Revised

3/1/2026

See updated policy for details.

Cinqair®

Revised

3/1/2026

See updated policy for details.

Commercial effective 2/1/2026

Abbreviations: E/I – Experimental/investigational; INV – Investigational; MA – Medicare Advantage; MN – Medically Necessary; MP – Medical Policy; NMN – Not Medically Necessary; PA – Preauthorization
Policy name
Policy number
Action
Highlights

Kidney transplants, pancreas transplants, and simultaneous kidney-pancreas transplant

9.005

Revised

Procedure code 48556 will no longer require PA.

Compression devices for treatment of lymphedema and peripheral vascular disease

6.013

Revised
  • Added a third allowance for programmable pneumatic pumps.
  • Pneumatic pumps are now MN with criteria for the chest and trunk.
  • Non-pneumatic pumps are now MN with criteria for lymphedema.

Commercial effective 3/1/2026

Abbreviations: E/I – Experimental/investigational; INV – Investigational; MA – Medicare Advantage; MN – Medically Necessary; MP – Medical Policy; NMN – Not Medically Necessary; PA – Preauthorization
Policy name
Policy number
Action
Highlights

Semi-implantable and fully implantable middle ear hearing aid

1.130

Revised
  • Procedure codes S2230 and V5095 will no longer require PA.
  • Added procedure codes 0951T-0995T.
  • Policy has been changed from MN to INV.

Medicare effective 2/1/2026

Abbreviations: E/I – Experimental/investigational; INV – Investigational; MA – Medicare Advantage; MN – Medically Necessary; MP – Medical Policy; NMN – Not Medically Necessary; PA – Preauthorization
Policy name
Policy number
Action
Highlights

Nonpharmacologic treatment of rosacea

2.071

Revised

Removed procedure codes: 15781, 17000, 17003, and 17004.

Medicare Advantage and commercial effective 2/1/2026

Abbreviations: E/I – Experimental/investigational; INV – Investigational; MA – Medicare Advantage; MN – Medically Necessary; MP – Medical Policy; NMN – Not Medically Necessary; PA – Preauthorization
Policy name
Policy number
Action
Highlights

Vagus nerve and implantable peripheral nerve stimulators

1.034

Revised
  • Procedure codes 64596 and 64598 will no longer require PA for Commercial, is now non-covered.
  • Procedure codes 64570 and L8681 will no longer require PA for MA.

Investigational miscellaneous genetic and molecular tests

2.277

Revised

Added procedure codes: 0046U, 0049U, 0436U and 81246.

Commercial retired medical policies effective 2/1/2026

Abbreviations: E/I – Experimental/investigational; INV – Investigational; Local Coverage Determination – LCD; MA – Medicare Advantage; MN – Medically Necessary; MP – Medical Policy; National Coverage Determination – NCD; NMN – Not Medically Necessary; PA – Preauthorization
Policy name
Policy number
Highlights

Clinical Trials

2.010

Retirement.

Parenteral Nutrition

3.008

Retirement.

Therapeutic Radiopharmaceuticals for Neuroendocrine Tumors

2.371

Retirement.

Medicare Advantage retired medical policies effective 2/1/2026

Abbreviations: E/I – Experimental/investigational; INV – Investigational; Local Coverage Determination –LCD; MA – Medicare Advantage; MN – Medically Necessary; MP – Medical Policy; National Coverage Determination – NCD; NMN – Not Medically Necessary; PA – Preauthorization
Policy name
Policy number
Highlights

Durable Medical Equipment (DME) and supplies

6.026
  • Retirement.
  • Procedure code E0636 will no longer require PA.
  • Refer to the Local Coverage Determination (LCD) or the National Coverage Determination (NCD).

Heart-lung transplant

9.014
  • Retirement.
  • Refer to the LCD or the NCD.

Implantable infusion pumps for pain and spasticity

1.058
  • Retirement.
  • Procedure codes: C1772, C1891, C2626, E0782, E0783, E0785, and E0786 will no longer require PA.

Isolated small bowel transplant and small bowel/liver and multivisceral transplant

9.013
  • Retirement.
  • Procedure codes: 44715, 44720, 44721, 47133, 47135, 47140-47147 will no longer require PA.
  • Refer to the LCD or the NCD.

Kidney transplants, pancreas transplants, and simultaneous kidney-pancreas transplant

9.005
  • Retirement.
  • Procedure code 48556 will no longer require PA.
  • Refer to the LCD or the NCD.

Cardiac hemodynamic monitoring for the management of heart failure in the outpatient setting

2.051
  • Retirement.
  • Procedure codes: 93050, 93264, G0555, and C2624 will no longer require PA.
  • Procedure codes: 0607T, 0608T, 0933T, and 0934T have been removed and placed on MA 4.002.

Confocal laser endomicroscopy

2.093
  • Retirement.
  • Procedure codes 0397T and 88375 have been removed and placed on MA 4.002.
  • Refer to the LCD or the NCD.

Cosmetic and reconstructive

1.004
  • Retirement.
  • Procedure codes; K0591, 0419T, 0420T, 17340, 69090 will be moving to MA 4.002.
  • Refer to the LCD or the NCD.

Dry needling of trigger points for myofascial pain

4.041

Retirement.

Gene expression profiling for cutaneous melanoma

2.396
  • Retirement.
  • Procedure code 0490U will be moving to MP 2.277.

Genetic testing for FLT3, NPM1 and CEBPA variants in cytogenetically normal acute Myeloid Leukemia

2.357
  • Retirement.
  • Procedure codes 0046U, 0049U, and 81246 will be moved to MP 2.277.
  • Refer to the LCD or the NCD.

Genetic testing for hereditary pancreatitis

2.318
  • Retirement.
  • Refer to the LCD or the NCD.

Genetic testing for inherited thrombophilia

2.253
  • Retirement.
  • Refer to the LCD or the NCD.

Interventions for progressive scoliosis

1.120
  • Retirement.
  • Procedure code L1001 was changed from non-covered to covered.
  • Refer to the LCD or the NCD.

Investigational physical medicine and specialized physical medicine interventions (Outpatient)

8.001
  • Retirement.
  • Refer to the LCD or the NCD.

Liver transplant and combined liver-kidney transplant

9.006
  • Retirement.
  • Refer to the LCD or the NCD.

Molecular analysis for targeted therapy for non-small cell lung cancer

2.241
  • Retirement.
  • Procedure code 0436U will be moved to MP 2.277.
  • Refer to the LCD or the NCD.

Off-label use of medications and other interventions

2.103

Retirement.

Percutaneous electrical nerve field stimulation, cranial electrotherapy stimulation, auricular electrostimulation, and external trigeminal nerve stimulation

2.092

Retirement.

Positron emission mammography

5.008

Retirement.

Pharyngometry and rhinometry

2.088
  • Retirement.
  • Procedure code 92512 has changed from INV to covered.

Serum antibody markers for diagnosing inflammatory bowel disease

2.222
  • Retirement.
  • Refer to the LCD or the NCD.

Serum biomarkers for human epididymis protein 4-HE4

2.269
  • Retirement.
  • Procedure code 86305 will be moved to MA 4.002.

Somatic biomarker testing for Immune Checkpoint Inhibitor Therapy (MSI/MMR, PD-L1, TMB)

2.388
  • Retirement.
  • Refer to the LCD or the NCD.

Step therapy treatments of stage four, advanced metastatic cancer and severe related health conditions

2.373

Retirement.

Steroid-eluting sinus stents and implants

1.140
  • Retirement.
  • Procedure code J7402 will be moved to MA 4.002.

Medicare Advantage retired medical policies effective 3/1/2026

Abbreviations: E/I – Experimental/investigational; INV – Investigational; Local Coverage Determination –LCD; MA – Medicare Advantage; MN – Medically Necessary; MP – Medical Policy; National Coverage Determination – NCD; NMN – Not Medically Necessary; PA – Preauthorization
Policy name
Policy number
Highlights

Semi-implantable and fully implantable middle ear hearing aid

1.130

Retirement.

Commercial and Medicare Advantage retired medical policies effective 2/1/2026

Abbreviations: E/I – Experimental/investigational; INV – Investigational; Local Coverage Determination –LCD; MA – Medicare Advantage; MN – Medically Necessary; MP – Medical Policy; National Coverage Determination – NCD; NMN – Not Medically Necessary; PA – Preauthorization
Policy name
Policy number
Highlights

Viral tropism testing

2.208

Retirement.

Commercial and Medicare Advantage retired medical policies effective 3/1/202

Abbreviations: E/I – Experimental/investigational; INV – Investigational; Local Coverage Determination –LCD; MA – Medicare Advantage; MN – Medically Necessary; MP – Medical Policy; National Coverage Determination – NCD; NMN – Not Medically Necessary; PA – Preauthorization
Policy name
Policy number
Highlights

Bronchial thermoplasty

2.081
  • Retirement.
  • Procedure codes 31660 and 31661 will no longer require PA and will be moved to 4.002.