Administrative bulletin: 2026-06-004 Medical policies

Date: June 1, 2026

Effective Date: July 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 Commercial medical injectable policies, visit Prime Therapeutics. To view Medicare medical injectable policies, visit Capital’s Medicare medical policies page and click on the Medical Drugs, Biologics, and Diabetes Supplies dropdown.

Codes that require preauthorization are maintained on the Capital Blue Cross Single source preauthorization list located on the CapBlueCross.com 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 has updated medical specialty policies (Commercial only) to be more medication-specific. The clinical criteria have been updated, along with the appearance and formatting of the policies.

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.

Note: To view Medicare medical injectable policies, visit Capital’s Medicare medical policies page and click on the Medical Drugs, Biologics, and Diabetes Supplies dropdown.

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

Loargys®

New

7/1/2026

J3590 and C9399 will now require PA for new drug Loargys

Exdensur®

New

7/1/2026

J3590 and C9399 will require PA for new drug Exdensur; PA requirements were extended from a 6/1 effective date to a 7/1 effective date.

Revcovi®

Revised

8/1/2026

See updated policy for details.

Adzynma®

Revised

8/1/2026

See updated policy for details

Akynzeo® IV

Revised

8/1/2026

See updated policy for details

Aldurazyme®

Revised

8/1/2026

See updated policy for details.

Alpha-1 Proteinase Inhibitors

Revised

8/1/2026

See updated policy for details.

Bavencio®

Revised

8/1/2026

See updated policy for details.

Beleodaq®

Revised

8/1/2026

See updated policy for details.

Brineura

Revised

8/1/2026

See updated policy for details.

Cinvanti®

Revised

8/1/2026

See updated policy for details.

Elaprase®

Revised

8/1/2026

See updated policy for details.

Elelyso®

Revised

8/1/2026

See updated policy for details.

Elfabrio®

Revised

8/1/2026

See updated policy for details.

Fabrazyme®

Revised

8/1/2026

See updated policy for details.

Fosaprepitant IV

Revised

8/1/2026

See updated policy for details.

Imfinzi®

Revised

8/1/2026

See updated policy for details.

Imjudo®

Revised

8/1/2026

See updated policy for details.

Jemperli

Revised

8/1/2026

See updated policy for details.

Kanuma®

Revised

8/1/2026

See updated policy for details.

Lamzede®

Revised

8/1/2026

See updated policy for details.

LenmeldyTM

Revised

8/1/2026

See updated policy for details.

Libtayo®

Revised

8/1/2026

See updated policy for details.

Loqtorzi®

Revised

8/1/2026

See updated policy for details.

Lumizyme®

Revised

8/1/2026

See updated policy for details.

Mepsevii®

Revised

8/1/2026

See updated policy for details.

MylotargTM

Revised

8/1/2026

See updated policy for details.

Naglazyme®

Revised

8/1/2026

See updated policy for details.

Nexviazyme®

Revised

8/1/2026

See updated policy for details.

Penpulimab-KCQX

Revised

8/1/2026

See updated policy for details.

Pombiliti®

Revised

8/1/2026

See updated policy for details.

Poteligeo®

Revised

8/1/2026

See updated policy for details.

Reblozyl®

Revised

8/1/2026

See updated policy for details.

Rituximab IV

Revised

8/1/2026

See updated policy for details.

Rituxan Hycela®

Revised

8/1/2026

See updated policy for details.

Romidepsin

Revised

8/1/2026

See updated policy for details.

Tecentriq® IV

Revised

8/1/2026

See updated policy for details.

Tevimbra®

Revised

8/1/2026

See updated policy for details.

UnloxcytTM

Revised

8/1/2026

See updated policy for details.

Vimizim

Revised

8/1/2026

See updated policy for details.

VPRIV®

Revised

8/1/2026

See updated policy for details.

Xenpozyme®

Revised

8/1/2026

See updated policy for details.

Zynyz®

Revised

8/1/2026

See updated policy for details.

Commercial effective 7/1/2026

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

Noninvasive Imaging for the Evaluation and Monitoring of Patients with Chronic Liver Disease

MP 2.252

Revised

Change in title; formerly Non-Invasive Imaging Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease.

Removed multianalyte assays and associated procedure codes: 0002M, 0003M, 0166U, 0344U, 0468U, 81517, 81596, 83520, 83883. Will now be managed by EviCore.

Allergy Testing and Immunotherapy

MP 2.001

Revised

Updated oral food change test to include open, single-blind, and double-blind challenges.

Removed procedure codes: 82785, 83516, 86001, 86003, 86005, 86008, 86160, 86332, 86343, 86849, 0165U, 0178U. Will now be managed by EviCore

Bariatric Surgery

MP 1.015

Revised

SADI-S (Single anastomosis duodeno-ileal bypass with SG) is now medically necessary, was INV.

Confocal Laser Endomicroscopy

MP 2.093

Revised

Removed procedure code 88375, will now be managed by EviCore.

Durable Medical Equipment (DME) and Supplies

MP 6.026

Revised

Removed procedure code G0249 and associated DME item. Will now be managed by EviCore.

Orthopedic Applications of Platelet Rich Plasma

MP 4.039

Revised

Removed procedure code P9020, will now be managed by EviCore.

Recombinant and Autologous Platelet Derived Growth Factors as Treatment of Wound Healing and Other Non-orthopedic Conditions

MP 2.033

Revised

Removed procedure codes P9020 and 86999, will now be managed by EviCore.

Temporomandibular Disorder

MP 2.062

Revised

Removed procedure code P9020, will now be managed by EviCore.

Commercial effective 8/1/2026

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

Medical Treatments for Autism Spectrum Disorder

MP 2.304

Revised

Removed statements regarding first and second tier genetic testing.

Removed procedure codes: 81302, 81303, 81304, 81321, 81322, 81323, 96041, and S0265. Will now be managed by EviCore.

Remainder of the policy statements were updated.

Added procedure code 97533.

Vagus Nerve and Implantable Peripheral Nerve Stimulators

MP 1.034

Revised

Added Rheumatoid Arthritis to the INV statement.

Medicare Advantage and Commercial effective 7/1/2026

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

Measurement of Exhaled Nitric Oxide in the Diagnosis and Management of Asthma and other Respiratory Disorders

MP 4.038

MA 4.038

Revised

Change in title; formerly Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in Diagnosis and Management of Asthma and other Respiratory Disorders.

Removed criteria for exhaled breath condensate and associated procedure code 83987. Will now be managed by EviCore.

Experimental and Investigational Procedures

MP 4.002

MA 4.002

Revised

Removed procedure codes: 0889T, 0890T, 0891T, 0892T will now require Prior Authorization and will be managed with InterQual criteria.

Removed multiple procedure codes that will now be managed by EviCore.

Medicare Advantage and Commercial effective 8/1/2026

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

Restorative Neurostimulation Therapy

MA 1.034

New

New policy.

Commercial retired medical policies effective 7/1/2026

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

Abdominoplasty and Panniculectomy

MP 1.012

Retired

Retirement.

Abdominoplasty is discussed in MP 1.004.

Panniculectomy will be managed with InterQual criteria

Closure Devices for Patent Foramen Ovale and Atrial Septal Defects (ASD)

MP 1.039

Retired

Retirement. Will now be managed by TurningPoint.

Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)

MP 2.083

Retired

Retirement. Will now be managed by TurningPoint.

Transmyocardial Revascularization

MP 1.057

Retired

Retirement.

Medicare Advantage retired medical policies effective 7/1/2026

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

Implantable Bone-Conduction and Bone-Anchored Hearing Prosthetic Devices

MA 1.019

Retired

Retirement.

Procedure codes: 69714, 69716 and 69729 will no longer require prior authorization.

Commercial retired medical policies effective 7/1/2026

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

Policies listed below will be retired due to Evicore lab management program

Adjunctive Techniques for Screening, Surveillance, and Risk Classification of Barrett Esophagus and Esophageal Dysplasia

MP 2.390

BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia

MP 2.317

Carrier Screening for Genetic Disease

MP 2.258

Chromosomal Microarray Testing for the Evaluation of Pregnancy Loss

MP 7.028

Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)

MP 2.267

Cytochrome p450 Genotype Guided Treatment Strategy

MP 2.234

Evaluation of Biomarkers for Alzheimer Disease

MP 2.391

Gene Expression Based Assays for Cancers of Unknown Primary

MP 2.245

Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer

MP 2.315

Gene Expression Profiling for Cutaneous Melanoma

MP 2.396

Gene Expression Profiling for Uveal Melanoma

MP 2.360

Gene Expression Profiling, Protein Biomarkers, and Multimodal Artificial Intelligence for Prostate Cancer Management

MP 2.263

General Approach to Evaluating the Utility of Genetic Panels

MP 2.323

General Approach to Genetic Testing

MP 2.326

Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer

MP 2.280

Genetic Cancer Susceptibility Panels Using Next Generation Sequencing

MP 2.325

Genetic Testing for Limb Girdle Muscular Dystrophies

MP 2.332

Genetic Testing for Alpha 1-Antitrypsin Deficiency

MP 2.251

Genetic Testing for Alpha Thalassemia

MP 2.320

Genetic Testing for Alzheimer Disease

MP 2.050

Genetic Testing for Cardiac Ion Channelopathies

MP 2.233

Genetic Testing for CHARGE Syndrome

MP 2.322

Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies

MP 2.242

Genetic Testing for Diagnosis and Management of Mental Health Conditions

MP 2.264

Genetic Testing for Duchenne and Becker Muscular Dystrophy

MP 2.257

Genetic Testing for Epilepsy

MP 2.262

Genetic Testing for Facioscapulohumeral Muscular Dystrophy

MP 2.321

Genetic Testing for Familial Cutaneous Malignant Melanoma (CDKN2A, CDK4)

MP 2.246

Genetic Testing for Fanconi Anemia

MP 2.362

Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia

MP 2.357

Genetic Testing for Helicobacter Pylori Treatment

MP 2.308

Genetic Testing for Hereditary Hearing Loss

MP 2.319

Genetic Testing for Hereditary Hemochromatosis

MP 2.312

Genetic Testing for Hereditary Pancreatitis

MP 2.318

Genetic Testing for Heterozygous Familial Hypercholesterolemia

MP 2.363

Genetic Testing for Idiopathic Dilated Cardiomyopathy

MP 2.328

Genetic Testing for Inherited Thrombophilia

MP 2.253

Genetic Testing for Li-Fraumeni Syndrome

MP 2.274

Genetic Testing for Lipoprotein(A) Variant(s) as a Decision Aid for Aspirin Treatment

MP 2.310

Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

MP 5.013

Genetic Testing for Macular Degeneration

MP 2.260

Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders

MP 2.331

Genetic Testing for Mitochondrial Disorders

MP 2.273

Genetic Testing for Neurofibromatosis

MP 2.358

Genetic Testing for Pathogenic FMR1 Variants (Including Fragile X Syndrome)

MP 2.276

Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy

MP 2.248

Genetic Testing for PTEN Hamartoma Tumor Syndrome

MP 2.255

Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies

MP 2.355

Genetic Testing of CADASIL Syndrome

MP 2.247

Genotype-Guided Tamoxifen Treatment

MP 2.307

Genotype-Guided Warfarin Dosing

MP 2.306

Genotyping for 9P21 Single Nucleotide Polymorphisms to Predict Risk of Cardiovascular Disease or Aneurysm

MP 2.311

Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Breast Cancer (BRCA1, BRCA2, PIK3CA, KI-67, RET, BRAF, ESR1, NTRK)

MP 2.393

Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency, NTRK)

MP 2.395

Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Prostate Cancer (BRCA1/2, Homologous Recombination Repair Gene Alterations, NTRK Gene Fusion)

MP 2.394

Germline Genetic Testing for Gene Variants Associated with Breast Cancer in Individuals at High Breast Cancer Risk (CHEK2, ATM, BARD1)

MP 2.279

Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High Risk-Cancers (BRCA1, BRCA2, PALB2)

MP 2.211

Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1, CTNNA1)

MP 2.384

Germline Genetic Testing for Pancreatic Cancer Susceptibility Genes (ATM, BRCA1, BRCA2, CDKN2A, EPCAM, MLH1, MSH2, MSH6, PALBS, PMS2, STK11, and TP53)

MP 2.392

Invasive Prenatal (Fetal) Diagnostic Testing

MP 2.278

JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms

MP 2.281

KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy

MP 2.309

Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients with Cancer

MP 2.354

Molecular Markers in Fine Needle Aspirates of the Thyroid

MP 2.275

Molecular Panel Testing of Cancers to Identify Targeted Therapies

MP 2.259

Molecular Testing for Germline Variants Associated with Ovarian Cancer (BRIP1, RAD51C, RAD51D, NBN)

MP 2.377

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

MP 2.266

Molecular Testing in the Management of Pulmonary Nodules

MP 2.375

Multicancer Early Detection Testing

MP 2.387

Multimarker Serum Testing Related to Ovarian Cancer

MP 2.270

Next-Generation Sequencing for the Assessment of Measurable Residual Disease

MP 2.379

Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA

MP 2.261

Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines

MP 2.218

Preimplantation Genetic Testing

MP 7.009

Proteogenomic Testing for Patients with Cancer

MP 2.343

Proteomic Testing for Targeted Therapy in Non-Small Cell Lung Cancer

MP 2.337

Serum Antibody Markers for Diagnosing and Monitoring Inflammatory Bowel Disease

MP 2.222

Serum Biomarkers for Human Epididymis Protein 4 (HE4)

MP 2.269

Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Non-Small-Cell Lung Cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS, NTRK)

MP 2.241

Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment of Metastatic Colorectal Cancer (KRAS, NRAS, BRAF, NTRK, and HER2)

MP 2.316

Somatic Biomarker Testing for Immune Checkpoint Inhibitor Therapy (BRAF, MSI/MMR, PD-L1, TMB)

MP 2.388

Somatic Genetic Testing to Select Individuals with Melanoma or Glioma for Targeted Therapy or Immunotherapy (BRAF)

MP 2.364

Use of Common Genetic Variants (Single Nucleotide Polymorphisms) to Predict Risk of Non-Familial Breast Cancer

MP 2.249

Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders

MP 2.324

Medicare Advantage and Commercial retired medical policies effective 7/1/2026

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

Policies listed below will be retired due to Evicore lab management program

Investigational and Miscellaneous Genetic and Molecular Tests

MP 2.277

MA 2.277

Medicare Advantage and Commercial retired medical policies effective 7/1/2026

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

Policies listed below will be retired due to Evicore lab management program

B-Hemolytic Streptococcus Testing

G2159

Biomarker Testing for Autoimmune Rheumatic Disease

G2022

Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases

G2123

Biomarkers for Myocardial Infarction and Chronic Heart Failure

G2150

Bone Turnover Markers Testing

G2051

Cardiovascular Disease Risk Assessment

G2050

Celiac Disease Testing

G2043

Coronavirus Testing in the Outpatient Setting

G2174

Diabetes Mellitus Testing

G2006

Diagnosis of Idiopathic Environmental Intolerance

G2056

Diagnosis of Vaginitis

M2057

Diagnostic Testing of Influenza

G2119

Diagnostic Testing of Iron Homeostasis and Metabolism

G2011

Epithelial Cell Cytology In Breast Cancer Risk Assessment

G2059

Evaluation of Dry Eyes

G2138

Fecal Analysis in The Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing

G2060

Fecal Calprotectin Testing

G2061

Flow Cytometry

F2019

Folate Testing

G2154

Gamma-Glutamyl Transferase (GGT)

G2173

General Inflammation Testing

G2155

Helicobacter Pylori Testing

G2044

Identification of Microorganisms using Nucleic Acid Probes

M2097

Immune Cell Function Assay

G2098

In Vitro Chemoresistance and Chemosensitivity Assays

G2100

Intracellular Micronutrient Analysis

G2099

Lyme Disease

G2143

Nerve Fiber Density Testing

M2112

Onychomycosis Testing

M2172

Oral Cancer Screening and Testing

G2113

Pancreatic Enzyme Testing for Acute Pancreatitis

G2153

Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing

G2164

Pathogen Panel Testing

G2149

Prenatal Testing for Fetal Aneuploidy

G2055

Prescription Medication and Illicit Drug Testing in the Outpatient Setting

T2015

Prostate Biopsy Specimen Analysis

G2007

Salivary Hormone Testing

G2120

Serum Testing for Evidence of Mild Traumatic Brain Injury

G2151

Testing for Diagnosis of Active or Latent Tuberculosis

G2063

Testing for Vector-Borne Infections

G2158

Testosterone

G2013

Thyroid Disease Testing

G2045

Urinary Tumor Markers for Bladder Cancer

G2125

Urine Culture Testing for Bacteria

G2156

Vitamin B12 and Methylmalonic Acid Testing

G2014

Vitamin D Testing

G2005