Administrative bulletin: 2026-07-001 Updates and new information

Date: July 1, 2026

Topics covered in this administrative bulletin are applicable to:

Professional and facility Providers

Professional Providers only

Unless otherwise noted, if you have any questions regarding the information in this bulletin, please contact your Provider Engagement Consultant or visit capbluecross.com/wps/portal/cap/provider/pec-look-up and enter your NPI or Tax ID to identify your designated point of contact at Capital Blue Cross.

Professional and facility Providers

Evolent – High-tech radiology and cardiac imaging – Preauthorization and medical policy updates

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

KEY POINT: Effective August 1, 2026, Capital will sunset the delegation of high-tech radiology and cardiac imaging services through Evolent for the Medicare and CHIP lines of business.

  • For CHIP, high-tech radiology and cardiac imaging services will no longer require preauthorization.
  • For Medicare Advantage, most high-tech radiology and cardiac imaging services will no longer require preauthorization, with a few exceptions outlined below. For those exceptions, preauthorization and utilization management will transition to Capital effective August 1, 2026.
  • For Commercial, high-tech radiology and cardiac imaging services will continue to require preauthorization through Evolent.

Effective August 1, 2026, the following policies will retire from the Medicare medical policy library.

Evolent Medicare Advantage policy retirements effective August 1, 2026
Procedure code
Description

Evolent CG 2002

Abdomen (CTA)

Evolent CG 2005

Abdomen Pelvis (CTA)

Evolent CG 2006

Abdominal Aorta (CTA) with Lower Extremity Runoff

Evolent CG 2007

Bone Marrow (MRI)

Evolent CG 2009

Brain (CTA)

Evolent CG 2010

Magnetic Resonance Spectroscopy (MRS)

Evolent CG 2015

Cerebral Perfusion (CT)

Evolent CG 2020

Chest (CTA)

Evolent CG 2022

Computed Tomography (CT) (Virtual) Colonoscopy – Diagnostic

Evolent CG 2033

Lower Extremity (CTA)

Evolent CG 2038

Magnetic Resonance Elastography (MRE)

Evolent CG 2040

Neck (CTA)

Evolent CG 2043

Pelvis (CTA)

Evolent CG 2063

Upper Extremity (CTA)

Evolent CG 2068

Brain and Neck (CTA)

Evolent CG 7272

Coronary Artery Calcium Scoring by (EBCT)

Evolent CG 7311

Multiple Gated Acquisition Scan (MUGA)

Evolent CG 7312

Myocardial Perfusion Imaging (MPI)

Effective August 1, 2026, the following procedure codes will no longer require preauthorization for Medicare Advantage and CHIP.

Preauthorization is no longer required for Medicare Advantage and CHIP effective August 1, 2026
Procedure code
Description

70336

MRI temporomandibular joint

70450, 70460, 70470

CT head/brain

70471

CT angiography, head and neck

70473

Cerebral perfusion analysis CT

70480, 70481, 70482

CT orbit

70486, 70487, 70488

CT maxillofacial/sinus

70490, 70491, 70492

CT soft tissue neck

70496

CT angiography, head

70498

CT angiography, neck

70540, 70542, 70543

MRI orbit, face, neck and/or internal auditory canal

70544, 70545, 70546

MRA head

70547, 70548, 70549

MRA neck

70551, 70552, 70553

MRI brain (with or without internal auditory canal views)

70554, 70555

Functional MRI brain

71250, 71260, 71270

CT chest

71275

CT angiography, chest (non coronary)

71550, 71551, 71552

MRI chest

71555

MRA chest (excluding myocardium)

72125, 72126, 72127

CT cervical spine

72128, 72129, 72130

CT thoracic spine

72131, 72132, 72133

CT lumbar spine

72141, 72142, 72156

MRI cervical spine

72146, 72147, 72157

MRI thoracic spine

72148, 72149, 72158

MRI lumbar spine

72159

MRA spinal canal

72191

CT angiography, pelvis

72192, 72193, 72194

CT pelvis

72195, 72196, 72197

MRI pelvis

72198

MRA pelvis

73200, 73201, 73202

CT upper extremity

73206

CT angiography, upper extremity

73218, 73219, 73220

MRI upper extremity, other than joint

73221, 73222, 73223

MRI upper extremity joint

73225

MRA upper extremity

73700, 73701, 73702

CT lower extremity

73706

CT angiography, lower extremity

73718, 73719, 73720, 73721, 73722, 73723

MRI lower extremity

72195, 72196, 72197, 73721, 73722, 73723

MRI hip

73725

MRA lower extremity

74150, 74160, 74170

CT abdomen

74175

CT angiography, abdomen

74174

CT angiography, abdomen and pelvis

74176, 74177, 74178

CT abdomen and pelvis combination

74181, 74182, 74183

MRI abdomen (with or without MRCP)

74185

MRA abdomen

74261, 74262

Diagnostic CT colonoscopy (virtual colonoscopy, CT colonography)

74712

Fetal MRI

75557, 75559, 75561, 75563

MRI heart

75571, S8092

Coronary artery CA score, heart scan, ultrafast CT heart, electron beam CT

75572

CT heart

75573

CT heart congenital studies, non-coronary arteries

75635

CT angiography, abdominal aorta with lower extremity runoff

76380

Follow up, limited or localized CT

76390

MR spectroscopy

76391

Magnetic resonance elastography (MRE)

77046, 77047, 77048, 77049

MRI breast

77084

MRI bone marrow

78472, 78473, 78494

Muga scan

78608, 78609

PET scan, brain

78803, 78830, 78831, 78832

Radiopharmaceutical tumor localization (SPECT)

78811, 78812, 78813, 78814, 78815, 78816

PET scan

78811, 78812, 78813, 78814, 78815, 78816

PET scan with concurrently acquired CT for attenuation correction and anatomic localization.

93303, 93304, 93306, 93307, 93308

Transthoracic echocardiography (TTE)

93312, 93313, 93314, 93315, 93316, 93317, 93318

Transesophageal echocardiography (TEE)

G0219

Pet imaging, whole body, melanoma for non-covered indications

G0252

Pet imaging, initial diagnosis of breast cancer and/or surgical planning for breast cancer

Effective August 1, 2026, the following services will require preauthorization through Capital for Medicare Advantage. They will no longer require preauthorization for CHIP.

Preauthorization is required for Medicare Advantage through Capital
Procedure code
Description

78459, 78491, 78492, 78429, 78430, 78431, 78432, 78433

Heart PET scan with CT for attenuation

78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481, 78483, 78499

Myocardial perfusion imaging

78459, 78491, 78492

Heart PET scan

93350, 93351

Stress echocardiography

A complete list of CPT/HCPCS codes requiring preauthorization can be found on Capital's Single source preauthorization list.

NR-30.029 Services not Separately Reimbursed – Retirement and replacement with new consolidated policy and addition of new codes

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

KEY POINT: The Network Policy NR-30.029 Services Not Separately Reimbursed will be retired effective August 31, 2026. A new policy, FP-01.008 Services Not Separately Reimbursed, will be implemented effective September 1, 2026. New codes are added to the policy that will no longer be separately reimbursed effective September 1, 2026.

This policy transition adds new codes to the policy and consolidates existing guidance into a single, comprehensive policy that applies to both Facility and Professional providers.

Effective September 1, 2026, Capital Blue Cross will no longer reimburse for the following codes for Commercial.

Procedure code

Description

99374

Supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (e.g., Alzheimer's facility) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes.

99375

Supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (e.g., Alzheimer's facility) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more.

G0179

Physician or allowed practitioner re-certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians and allowed practitioners to affirm the initial implementation of the plan of care.

G0180

Physician or allowed practitioner certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians or allowed practitioners to affirm the initial implementation of the plan of care.

G0181

Physician or allowed practitioner supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician or allowed practitioner development and/or revision of care plans.

G0574

Management of new patient with dementia residing in an eligible residential care community, for use only in a Medicare-approved CMMI Model (Services must be furnished within a patient's eligible residential care community, including assisted living facilities, board and care homes, or other qualifying residential settings where dementia care services are provided).

G0575

Management of established patient with dementia residing in an eligible residential care community, for use only in a Medicare-approved CMMI Model (Services must be furnished within a patient's eligible residential care community, including assisted living facilities, board and care homes, or other qualifying residential settings where dementia care services are provided).

G0669

Outcome-aligned payment (OAP) for technology-enabled chronic care management of early cardio-kidney-metabolic (ECKM) conditions (hypertension, or two or more of: dyslipidemia, obesity/overweight with central obesity marker, prediabetes); Initial 12-Month Period; per month.

G0670

Outcome-aligned payment (OAP) for technology-enabled chronic care management of early cardio-kidney-metabolic (ECKM) conditions (hypertension, or two or more of: dyslipidemia, obesity/overweight with central obesity marker, prediabetes); Follow-on 12-Month Period; per month.

G0671

Outcome-aligned payment (OAP) for technology-enabled chronic care management of cardio-kidney-metabolic (CKM) conditions (one or more of: diabetes mellitus, chronic kidney disease stage 3A or 3B, atherosclerotic cardiovascular disease); Initial 12-Month Period; per month.

G0672

Outcome-aligned payment (OAP) for technology-enabled chronic care management of cardio-kidney-metabolic (CKM) conditions (one or more of: diabetes mellitus, chronic kidney disease stage 3A or 3B, atherosclerotic cardiovascular disease); Follow-on 12-Month Period; per month.

G0673

Outcome-aligned payment (OAP) for technology-enabled chronic care management of musculoskeletal (MSK) conditions (chronic musculoskeletal pain); initial 12-Month Treatment Period; per month.

G0676

Standard co-management service payment for documented review of clinical updates from access participant managing cardio-kidney-metabolic conditions (early cardio-kidney-metabolic (ECKM) or cardio-kidney-metabolic (CKM) track); per review.

G0677

Standard co-management service payment for documented review of clinical updates from access participant managing musculoskeletal (MSK) conditions; per review.

Effective September 1, 2026, Capital Blue Cross will no longer reimburse for the following codes for Commercial and Medicare Advantage.

Procedure code

Description

69209

Removal of impacted cerumen using irrigation/lavage, unilateral.

76376

3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation.

76377

3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation.

New reimbursement policy – FP-01.011 Obstetrical Maternity Services

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

KEY POINT: Capital Blue Cross has created reimbursement policy FP-01.011 – Obstetrical Maternity Services that will go into effect on September 1, 2026, preparing providers for CPT® coding changes for 2027, transitioning away from global obstetric codes in favor of visit-based service reporting.

Overview of Changes:

Prior to September 1, 2026, (global-based billing) – Patients presenting for their first prenatal visit after the confirmation of pregnancy will continue to use bundled codes:

  • 59425 (Antepartum care only; 4-6 visits)
  • 59426 (Antepartum care only; 7 or more visits)

On or after September 1, 2026, (visit/service based billing) – Patients presenting for their first prenatal visit after confirmation of pregnancy will require the use of:

  • Evaluation and management (E/M) codes with the HCPCS modifier “TH" – Obstetrical treatment/services, prenatal or postpartum.
  • Claims must include the appropriate ICD-10-CM codes, including the weeks of gestation Z3A.XX. (“XX” defines week of gestation. I.e., Z3A.15 equals 15 weeks gestation.)
  • Documentation must support medical decision-making or time consistent with current CPT guidelines.

The E/M level reported should reflect the service provided during the encounter, considering the presenting problem, the amount and/or complexity of data reviewed, and the risk of complications and/or morbidity or mortality associated with patient management. The “TH" modifier appended to the E/M code will differentiate the visit as related to the prenatal or postpartum visit. Providers are responsible for ensuring that documentation accurately reflects the patient's severity and the services rendered.

Reimbursement Policy FP-01.011 also addresses the following obstetrics and maternity services transitioning from global-based billing to visit/service-based billing effective January 1, 2027.

  • Labor management – Codes (e.g., 59080-59083, 59030, and 59051) are used to report interim physical examinations, the collection and interpretation of physiologic data, and the induction or augmentation of labor. The initial day of labor management may be reported once per facility admission unless services are provided by a different provider. A face‑to‑face encounter is required and may be billed once per calendar date. Multiple visits by the same physician or qualified health care professional (QHP) within the same setting on a single calendar date must be reported as a single labor management service. A continuous encounter that spans two calendar dates should be reported as one service on either of the two dates.
  • Delivery care – Codes (e.g., 59431-59504) are used once labor has been completed or interrupted and may be reported on the same day as initial or subsequent labor management services, even when both services are provided by the same physician or qualified health care professional.
  • Postpartum care – Use codes (e.g., 59623, 59610, 59350) appended to E/M codes. Routine postpartum care provided on the same calendar date as the delivery is not separately reportable; it is included in the delivery care code. For a facility birth, postpartum care may be billed using the appropriate subsequent hospital care E/M codes for each management day until discharge, as well as the applicable discharge day management codes.

Preventive services health coverage guidelines — 2026 updates

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

KEY POINT: Effective July 1, 2026, the following updates have been made to the Preventive Services Health Coverage Guidelines.

The July 2026 guidelines were updated to include the following:

Preventive service(s)

Action

Highlights

CONTRACEPTIVE DEVICES/SUPPLIES

Revised

Revised procedure codes to include J7299.

To ensure preventive services for members are covered with no cost-share when applicable, Providers are reminded to reference the Preventive Services Health Coverage Guidelines via our provider portal (Availity Essentials). They can be accessed by selecting the Resources tab > Provider Library > Education and manuals > under the Guidelines dropdown menu.

Single source preauthorization list updates

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

KEY POINT: Updates to the Single Source preauthorization list will occur as described below.

Effective August 1, 2026, the following procedure code(s) will not require preauthorization for Commercial and Medicare Advantage.

Commercial and Medicare Advantage effective August 1, 2026
Code
Description

V2785

Processing, preserving, and transporting corneal tissue

Effective September 1, 2026, the following procedure code(s) will require preauthorization for Medicare Advantage.

Medicare Advantage effective September 1, 2026
Code
Description

J1577

Injection, immune globulin-kthm (Qivigly), 100mg

J3405

Injection, onasemnogene abeparvovec-brve, per treatment

J1289

Injection, narsoplimab-wuug (Yartemlea)

J9053

Injection, belantamab mafodotin-blmf (Blenrep)

J9067

Injection, amivantamab and hyaluronidase-lpju (Rybrevant Faspro)

Q5165

Injection, denosumab-mobz (Oziltus), biosimilar, 1mg

Q5171

Injection, denosumab-mobz (Boncresa), biosimilar, 1mg

Q5166

Injection, denosumab-desu (Osyvrti/Jubereq), biosimilar, 1mg

Q5167

Injection, denosumab-qbde (Enoby/Xtrenbo), biosimilar, 1mg

J2361

Injection, depemokimab-ulaa (Exdensur)

Q5168

Injection, ranibizumab-leyk (Nufymco), biosimilar, 0.1mg

Q5169

Injection, pegfilgrastim-unne (Armlupeg), biosimilar, 0.5mg

Q5170

Injection, aflibercept-boav (Eydenzelt), biosimilar, 1mg

Effective immediately upon release from the drug manufacturer, the following procedure code(s) will require preauthorization for Medicare Advantage and Commercial.

Commercial and Medicare Advantage effective immediately upon release
Code
Description

J3386

Injection, Etuvetidigene Autotemcel (Waskyra), per treatment

Note: Codes that require preauthorization are maintained on the Capital Blue Cross Single source preauthorization list located on Capital’s provider web page.

Professional Providers only

Expanded reimbursement for rabies vaccine 90675 in urgent care settings

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

KEY POINT: Rabies Vaccine 90675 is now eligible for reimbursement in an Urgent Care setting.

Effective May 22, 2026, providers in Urgent Care settings can receive separate reimbursement for rabies vaccine CPT code 90675. Historically, reimbursement for CPT 90675 was bundled into the global payment rate associated with Urgent Care services.

It is important to note that while reimbursement methodology has changed, all existing billing and documentation requirements remain unchanged. Providers should continue to follow current guidelines to ensure accurate coding, compliance, and proper claim processing.