Capital Blue Cross Medical Policy Updates and Preauthorization Requirements

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

KEY POINT: Capital Blue Cross has updated the medical policies outlined below

Highlights are provided; however, providers should refer to the applicable draft policy for complete 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.

Where to Find Policies and Codes Requiring Authorization

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

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

Commercial
Effective December 1, 2026

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

Cartilage Implants for Joint Pain

MP 1.160

Revised

Change in title: formerly Synthetic Cartilage Implants for the First Metatarsophalangeal Joint.

Removed “synthetic” from policy statement and policy title.

Dermatologic Applications of Photodynamic Therapy

MP 4.018

Revised

Added diagnosis codes: D04.111 and D04.112.

Removed diagnosis code D04.11.

Durable Medical Equipment (DME) and Supplies

MP 6.026

Revised

Added procedure codes: A6515, A6516, A6517, A6518, A6519, A6540, A6611, E0465, E0466, E0467, E0468, E1035, E1036, K0739, K0900.

Removed procedure code E0221.

Commercial
Effective January 1, 2027

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

Off-Label Use of Devices and Other Interventions

MP 2.103

Revised

Change in title: formerly Off-Label Use of Medications and Other Interventions.

Removed language and associated criteria for off-label use of drugs and biologics. Prime will now manage.

Percutaneous Electrical Nerve Field Stimulation for Disorders of Gut-Brain Interaction

MP 2.397

Revised

Change in title: formerly Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel.

Clarified investigational statement to include disorders of gut-brain interaction.

Microprocessor Controlled Prostheses for the Lower Limbs

MP 6.036

Reinstated

Procedure codes L5827 and L5859 no longer require PA.

Procedure codes L5827 and L5859 from MN to NCV.
Indications for this policy have been relocated from MP 6.042, with criteria changes outlined below:

  • Removed two (2) MN bullet points related to functional level and medical record documentation.
  • Separated the MN criterion addressing physical and cognitive ability into two (2) distinct bullet points.
  • Changed powered knee from MN to INV.

Continuous Passive Motion in the Home Setting

MP 6.039

Revised

Use of device or systems featuring continuous passive motion with remote monitoring or adaptive capabilities are INV.

Lower Limb Prostheses

MP 6.042

Revised

Indications for microprocessor have been relocated to reinstated MP 6.036.

Commercial
RETIRED MEDICAL POLICIES
Effective December 1, 2026

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

Dengvaxia

MP 2.381

Retirement

Retirement.

Commercial
RETIRED MEDICAL POLICIES
Effective January 1, 2027

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

Orphan Drugs and Humanitarian Use Device

MP 2.383

Retirement

Retirement.

Capital Blue Cross Medical Policy Updates and Preauthorization Requirements

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

KEY POINT: Capital Blue Cross has updated the medical policies outlined below

For Commercial medical injectable policies, visit the Prime MPS GatewayPA Portal and select Capital Blue Cross under Clinical Guidelines.

Prior Authorization

If prior authorization is required, submit your request through the Prime MPS GatewayPA Portal. For urgent or expedited requests, or if prior authorization cannot be completed online, contact Prime MPS via:

Medicare: To view Medicare medical injectable policies, visit Capital’s Medicare medical policies page and select Medical Drugs, Biologics, and Diabetes Supplies for Medicare-specific information.

Important Note: Prior authorization periods for some drugs have changed to be consistent with clinical monitoring. Refer to the individual drug medical policy for the applicable

authorization period.

PRIME THERAPEUTICS

Medical Specialty Injectable Policy Updates (COMMERCIAL)
Policy Name
Action
Effective Date
Highlights

Revtorpyk

New

12/1/2026

J9999 and C9399 will now require preauthorization for new drug, Revtorpyk

Tregzi

New

12/1/2026

J3590 and C9399 will now require preauthorization for new drug Tregzi

Lumvoa

New

12/1/2026

J3590 and C9399 will now require preauthorization for new drug, Lumvoa

Lytenava

New

12/1/2026

J3590 will now require preauthorization for new drug, Lytenava

Omalizumab®

Revised

12/1/2026

Title change; Q5154 will now require preauthorization for new biosimilar, Omlyclo

Saphnelo

Revised

1/1/2027

New step therapy requirements; see updated policy for details.

Bevacizumab-Onco

Revised

1/1/2027

All indications except for ocular indications will now require PA; see updated policy for details.

Mandatory Site of Service

Revised

1/1/2027

Addition of 9 new drugs:

  • Q5151 Epysqli
  • Q5152 Bkemv
  • Q5156 Avtozma IV
  • Q5135 Tyenne
  • Q5167 Xtrenbo
  • Q5167 Enoby
  • Q5162 Bildyos
  • Q5162 Bilprevda
  • J2361 Exdensur

Off-Label Use of Pharmaceuticals

New

1/1/2027

Vendor policy to manage off-label drug utilization and orphan drugs

Factor VIII-vWF

Revised

1/1/2027

See updated policy for details

Avlayah™

Revised

1/1/2027

See updated policy for details.

Bendamustine

Revised

1/1/2027

See updated policy for details.

Beovu®

Revised

1/1/2027

See updated policy for details.

Cyramza®

Revised

1/1/2027

See updated policy for details.

Denosumab

Revised

1/1/2027

See updated policy for details.

Elahere®

Revised

1/1/2027

See updated policy for details.

Encelto™

Revised

1/1/2027

See updated policy for details.

Halaven®

Revised

1/1/2027

See updated policy for details.

Infliximab

Revised

1/1/2027

See updated policy for details.

Kyxata™

Revised

1/1/2027

See updated policy for details.

Paclitaxel Albumin Bound

Revised

1/1/2027

See updated policy for details.

Pemetrexed

Revised

1/1/2027

See updated policy for details.

Pluvicto®

Revised

1/1/2027

See updated policy for details.

Ranibizumab

Revised

1/1/2027

See updated policy for details.

Rytelo™

Revised

1/1/2027

See updated policy for details.

Sarclisa® IV

Revised

1/1/2027

See updated policy for details.

Susvimo®

Revised

1/1/2027

See updated policy for details.

Syfovre®

Revised

1/1/2027

See updated policy for details.

Trastuzumab IV

Revised

1/1/2027

See updated policy for details.

Vabysmo®

Revised

1/1/2027

See updated policy for details.

Vyloy®

Revised

1/1/2027

See updated policy for details.

Zaltrap®

Revised

1/1/2027

See updated policy for details.

Zepzelca®

Revised

1/1/2027

See updated policy for details.

EviCore - Laboratory Management Clinical Guideline Updates

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

KEY POINT: Effective January 1, 2027, EviCore will implement updated Clinical Guidelines for Lab Management Program, Version 1.0.2027.

EviCore's Clinical Guidelines for Lab Management Program, Version 1.0.2027, has been reviewed and approved by Capital Utilization Management committees for implementation effective January 1, 2027. This comprehensive policy manual outlines the clinical criteria that will be applied in both preservice utilization management determinations and post-service medical policy enforcement through claims editing for Capital members.

The Clinical Guidelines for Lab Management Program have been revised as follows.

Clinical Guidelines for Lab Management Program, Version 1.0.2027
Effective January 1, 2027
New Clinical Guidelines
  • Heath Equity Considerations - MOL.AD.439.A
  • Category III Laboratory Procedure Codes - MOL.CU.440.X
  • Inherited Retinal Disorder Genetic Testing - MOL.TS.441.A
  • Exome and Genome Sequencing - MOL.TS.442.A
Retired Clinical Guidelines
  • Exome Sequencing - MOL.TS.235.A
  • Select mdx - MOL.TS.264.A
  • Polymerase Gamma (POLG) Related Disorders Genetic Testing - MOL.TS.276.A
  • Genome Sequencing - MOL.TS.306.A
Substantive Criteria Updates for Clinical Guidelines
  • Special Circumstances Influencing Coverage Determinations - MOL.AD.364.A
  • Laboratory Billing and Reimbursement - MOL.AD.412.X
  • Sexually Transmitted and Other Reproductive Tract Infection Testing - MOL.CS.106.A
  • Respiratory Infection Pathogen Molecular Testing - MOL.CS.293.A
  • Drug Testing - MOL.CS.315.X
  • Cardiovascular Risk and Disease Laboratory Testing - MOL.CS.316.X
  • Thyroid Disorder Laboratory Testing - MOL.CS.320.X
  • Vitamin D Testing - MOL.CS.331.X
  • Inflammatory Bowel Disease Biomarker Testing - MOL.CS.359.X
  • Human Papillomavirus (HPV) Molecular Testing - MOL.CS.362.A
  • Prostate Specific Antigen Testing - MOL.CS.373.X
  • Non-Molecular Biomarkers in Oncology - MOL.CS.374.X
  • Testosterone Testing - MOL.CS.376.X
  • Cognitive Impairment Biomarkers - MOL.CS.400.X
  • Nail Disorder Infectious Disease Testing, Including Onychomycosis - MOL.CS.402.X
  • Reproductive Hormone Testing in Adults - MOL.CS.408.X
  • Vitamin Testing - MOL.CS.416.X
  • Mineral Testing - MOL.CS.417.X
  • Metabolic and Nutritional Testing - MOL.CS.418.X
  • Cologuard Plus Screening for Colorectal Cancer - MOL.CS.422.A
  • Genetic Testing to Predict Disease Risk - MOL.CU.115.A
  • Experimental, Investigational, or Unproven Laboratory Testing - MOL.CU.117.X
  • Pharmacogenomic Testing for Drug Toxicity and Response - MOL.CU.118.A
  • Charcot-Marie-Tooth Neuropathy Genetic Testing - MOL.TS.148.A
  • Chromosomal Microarray Testing For Developmental Disorders (Prenatal and Postnatal) - MOL.TS.150.A
  • HFE Hemochromatosis Genetic Testing - MOL.TS.183.A
  • PTEN Hamartoma Tumor Syndromes Genetic Testing - MOL.TS.223.A
  • Somatic Mutation Testing - MOL.TS.230.A
  • Epilepsy Genetic Testing - MOL.TS.257.A
  • Mitochondrial Disorders Genetic Testing - MOL.TS.266.A
  • Hereditary Pancreatitis Genetic Testing - MOL.TS.287.A
  • Decipher Prostate Cancer Classifier - MOL.TS.294.A
  • Human Platelet and Red Blood Cell Antigen Genotyping - MOL.TS.361.A
  • Inherited Thrombophilia Genetic Testing - MOL.TS.370.A
  • Hereditary Connective Tissue and Thoracic Aortic Disease Genetic Testing - MOL.TS.427.A
Non-Substantive Criteria Updates for Clinical Guidelines
  • 4Kscore for Prostate Cancer Risk Assessment - MOL.TS.120.A
  • Afirma Thyroid Cancer Classifier Tests - MOL.TS.122.A
  • Amyotrophic Lateral Sclerosis (ALS) Genetic Testing - MOL.TS.125.A
  • Familial Malignant Melanoma Genetic Testing - MOL.TS.170.A
  • Nonsyndromic Hearing Loss and Deafness Genetic Testing - MOL.TS.273.A
  • Gastrointestinal Pathogen Panel (GIPP) Molecular Testing - MOL.CS.277.A
  • Pathology Testing with Mohs Micrographic Surgery - MOL.CS.363.A
  • Special Histochemical Stains - MOL.CS.409.X
  • Cardiomyopathy and Arrhythmia Genetic Testing - MOL.TS.410.A
  • Laboratory Testing Procedure Code Requirements - MOL.AD.411.A
  • Primary Ciliary Dyskinesia Genetic Testing - MOL.TS.419.A
  • Insulin and Related Peptides - MOL.CS.423.X
  • Genetic Testing for Cancer Susceptibility and Hereditary Cancer Syndromes - MOL.CU.109.A
  • Genetic Testing for Carrier Status - MOL.CU.110.A
  • Genetic Testing for the Screening, Diagnosis, and Monitoring of Cancer - MOL.CU.113.A
  • Genetic Testing to Diagnose Non-Cancer Conditions - MOL.CU.114.A
  • Genetic Testing by Multigene Panels - MOL.CU.116.A
  • Alpha-1 Antitrypsin Deficiency Testing - MOL.TS.124.A
  • APOE Variant Analysis for Alzheimer Disease Testing - MOL.TS.128.A
  • Cystic Fibrosis Genetic Testing - MOL.TS.158.A
  • Duchenne and Becker Muscular Dystrophy Testing - MOL.TS.161.A
  • Early Onset Familial Alzheimer Disease Genetic Testing - MOL.TS.162.A
  • Familial Hypercholesterolemia Genetic Testing - MOL.TS.169.A
  • FMR1-Related Disorders (Fragile X) Genetic Testing - MOL.TS.172.A
  • Huntington Disease Genetic Testing - MOL.TS.188.A
  • Lynch Syndrome Tumor Screening - Second-Tier - MOL.TS.199.A
  • Mammaprint 70-Gene Breast Cancer Recurrence Assay - MOL.TS.200.A
  • Non-Invasive Prenatal Screening - MOL.TS.209.A
  • Oncotype DX for Breast Cancer Prognosis - MOL.TS.211.A
  • Prosigna Breast Cancer Prognostic Gene Signature Assay - MOL.TS.222.A
  • Spinal Muscular Atrophy Genetic Testing - MOL.TS.225.A
  • Tissue of Origin Testing for Cancer of Unknown Primary - MOL.TS.228.A
  • EndoPredict for Breast Cancer Prognosis - MOL.TS.234.A
  • Oncotype DX Breast DCIS - MOL.TS.255.A
  • Maturity-Onset Diabetes of the Young (MODY) Genetic Testing - MOL.TS.258.A
  • Autism, Intellectual Disability, and Developmental Delay Genetic Testing - MOL.TS.269.A
  • Limb-Girdle Muscular Dystrophy Genetic Testing - MOL.TS.288.A
  • Chromosome Analysis for Reproductive Disorders, Prenatal Testing, and Developmental Disorders - MOL.CS.289.A
  • Facioscapulohumeral Muscular Dystrophy Genetic Testing - MOL.TS.290.A
  • Genetic Testing for Known Familial Mutations - MOL.CU.291.A
  • Genetic Testing for Variants of Uncertain Clinical Significance - Genetic Testing for Variants of Uncertain Clinical Significance – MOL.CU.292.A
  • Legius Syndrome Genetic Testing - MOL.TS.302.A
  • Hemoglobinopathies Genetic Testing - MOL.TS.308.A
  • Myotonic Dystrophy Type 1 Genetic Testing - MOL.TS.312.A
  • Microsatellite Instability and Immunohistochemistry Testing in Cancer - MOL.TS.356.A
  • Inherited Bone Marrow Failure Syndrome (IBMFS) Testing - MOL.TS.360.A
  • Noonan Spectrum Disorder Genetic Testing - MOL.TS.371.A
  • Parathyroid Hormone Testing - MOL.CS.390.X
  • Infectious Disease Laboratory Testing - MOL.CU.398.X
  • Liver Fibrosis Assessment Biomarkers - MOL.CS.401.X
  • Hereditary Ataxia Genetic Testing - MOL.TS.425.A
  • Vitamin B12 and Folate Deficiency Testing - MOL.CS.426.X
  • Hereditary Cancer Syndrome Genetic Testing - MOL.TS.436.A
Clinical Guidelines, Reviewed and Renewed for 2027
  • Confirmatory Genetic Testing - MOL.CU.256.A
  • Genetic Testing for Non-Medical Purposes - MOL.CU.111.A
  • Genetic Testing for Prenatal Screening and Diagnostic Testing - MOL.CU.112.A
  • Hereditary (Germline) Testing After Tumor (Somatic) Testing - MOL.CU.246.A
  • Medically Necessary Laboratory Testing - MOL.CU.333.X
  • Preimplantation Genetic Testing - MOL.CU.119.A
  • Allergy Laboratory Testing - MOL.CS.317.X
  • AlloMap Gene Expression Profiling for Heart Transplant Rejection - MOL.TS.123.A
  • AlloSure for Kidney Transplant Rejection - MOL.TS.307.A
  • Angelman Syndrome Genetic Testing - MOL.TS.126.A
  • BCR-ABL Negative Myeloproliferative Neoplasm Genetic Testing - MOL.TS.240.A
  • Breast Cancer Index for Breast Cancer Prognosis - MOL.TS.248.A
  • CADASIL Genetic Testing - MOL.TS.144.A
  • CHARGE Syndrome and CHD7 Disorder Genetic Testing - MOL.TS.324.A
  • Carrier Screening Panels, Including Targeted, Pan-Ethnic, Universal, and Expanded - MOL.TS.165.A
  • Celiac Disease Testing - MOL.CS.319.X
  • Chromosomal Microarray for Solid Tumors - MOL.TS.344.A
  • Chromosome Analysis for Blood and Bone Marrow Cancers - MOL.TS.151.A
  • ColoSense Screening for Colorectal Cancer - MOL.TS.413.A
  • Cologuard Screening for Colorectal Cancer - MOL.TS.152.A
  • Confirm mdx - MOL.TS.153.A
  • Cxbladder - MOL.TS.236.A
  • DecisionDx Uveal Melanoma - MOL.TS.254.A
  • DermTech Melanoma Test - MOL.TS.282.A
  • Flow Cytometry - MOL.CS.103.A
  • Genomic Prostate Score - MOL.TS.295.A
  • Human Immunodeficiency Virus Laboratory Testing - MOL.CS.321.X
  • Helicobacter pylori Laboratory Testing - MOL.CS.318.A
  • Immunohistochemistry (IHC) - MOL.CS.104.A
  • Inflammatory Biomarkers - MOL.CS.420.X
  • Liquid Biopsy Testing - MOL.TS.194.A
  • Lyme Disease Testing - MOL.CS.332.X
  • Multi-Cancer Early Detection Screening - MOL.TS.396.A
  • Neurofibromatosis Type 1 Genetic Testing - MOL.TS.301.A
  • OvaSuite - MOL.TS.366.X
  • Obsolete Tests - MOL.CS.322.X
  • Oncotype DX for Colon Recurrence Score - MOL.TS.213.A
  • PCA3 Testing for Prostate Cancer - MOL.TS.215.A
  • Pancreatitis Laboratory Testing - MOL.CS.404.X
  • Prader-Willi Syndrome Genetic Testing - MOL.TS.217.A
  • Prenatal Aneuploidy FISH Testing - MOL.CS.218.A
  • Prenatal Maternal Serum Screening - MOL.CS.220.X
  • Prolaris - MOL.TS.297.A
  • Rheumatoid Arthritis Laboratory Testing - MOL.CS.369.X
  • SEPT9 Methylation Analysis for Colorectal Cancer - MOL.TS.164.A
  • ThyGeNEXT and ThyraMIR miRNA Gene Expression Classifier - MOL.TS.259.A
  • ThyroSeq - MOL.TS.270.A
  • Urinary Tract Infection Molecular Testing - MOL.CS.403.A
  • UroVysion FISH for Bladder Cancer - MOL.CS.108.A
  • Rett Syndrome Genetic Testing - MOL.TS.224.A
  • Date of Service and Authorization Period Effective Date - MOL.AD.314.A
  • Medical Necessity Review Information Requirements - MOL.AD.304.A
  • Medicare: Hierarchy for Applying Coverage Decisions for Laboratory Testing - MOL.AD.101.X
  • Unique Test Identifiers for Non-Specific Procedure Codes - MOL.AD.107.A

To preview EviCore’s Clinical Guidelines for Lab Management Program, Version 1.0.2027, select Future, and Capital Blue Cross Lab Management Guidelines Effective 01/01/2027-6/30/2027.

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

Disclaimer: Capital Blue Cross contracts with eviCore healthcare (EviCore), an independent company, to review requests for certain services for medical necessity and appropriateness.

Evolent High-Tech Radiology, Cardiac Imaging and Radiation Oncology Guideline Updates

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

KEY POINT: Effective January 1, 2027, Evolent will utilize updated medical policies in utilization management decisions for delegated High-Tech Radiology, Cardiac Imaging, and Radiation Oncology services.

All of Evolent’s medical policies and the delegated list of services have been reviewed and approved by Capital committees. Evolent is consolidating several individual medical policies into broader policies addressing similar services. Retired policies will continue to be managed under updated, consolidated guidelines.

The following medical policies have been revised, and changes will take effect January 1, 2027.

Commercial High-Tech Radiology and Cardiac Imaging
Effective January 1, 2027
New Clinical Guidelines
  • Heart Positron Emission Tomography (PET) with or without Computed Tomography (CT) for Attenuation – Evolent_CG_7346
  • Abdomen and Pelvis Imaging – Evolent_CG_2069
  • Brain Imaging Including Neck Vascular Imaging – Evolent_CG_2070
  • Chest Imaging – Evolent_CG_2071
  • Head and Neck Imaging Excluding Neck Vascular Imaging – Evolent_CG_2072
  • Lower Extremity Imaging Ankle, Foot, Hip, Knee, Lower Extremity – Evolent_CG_2073
  • Spine Imaging Cervical, Thoracic, Lumbar – Evolent_CG_2074
  • Upper Extremity Imaging Carpal Joint, Elbow, Hand, Humerus, Scapula, Shoulder, Upper Extremity Joint, Upper Extremity Non-Joint, Wrist – Evolent_CG_2075
  • Whole Body Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Including Bone Marrow MRI – Evolent_CG_2076
Retired Clinical Guidelines
  • CT Abdomen and Pelvis Combination – Evolent_CG_2000
  • CT Abdomen - Evolent_CG_2001
  • CT Angiography, Abdomen - Evolent_CG_2002
  • MRA Abdomen - Evolent_CG_2003
  • MRI Abdomen (with or without MRCP) - Evolent_CG_2004
  • CT Angiography, Abdomen and Pelvis - Evolent_CG_2005
  • CT Angiography, Abdominal Aorta with Lower Extremity Runoff - Evolent_CG_2006
  • MRI Bone Marrow - Evolent_CG_2007
  • CT Head/Brain - Evolent_CG_2008
  • CT Angiography, Head - Evolent_CG_2009
  • MR Spectroscopy - Evolent_CG_2010
  • MRA Head - Evolent_CG_2011
  • MRI Brain (with or without Internal Auditory Canal views) - Evolent_CG_2012
  • PET Scan, Brain - Evolent_CG_2013
  • Abdomen and Pelvis Imaging - Evolent_CG_2015
  • CT Cervical Spine - Evolent_CG_2016
  • MRI Cervical Spine - Evolent_CG_2017
  • CT Chest - Evolent_CG_2018
  • MRI Chest - Evolent_CG_2019
  • CT Angiography, Chest (non-coronary) - Evolent_CG_2020
  • Chest Magnetic Resonance Angiography (MRA) - Evolent_CG_2021
  • CT (Virtual) Colonoscopy – Screening  - Evolent_CG_2023
  • Computed Tomography (CT) Bone Density Study - Evolent_CG_2024
  • Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Guidance for Needle Biopsy - Evolent_CG_2026
  • Functional MRI Brain - Evolent_CG_2028
  • Low Dose CT for Lung Cancer Screening - Evolent_CG_2030
  • Low Field Magnetic Resonance Imaging (MRI) - Evolent_CG_2031
  • CT Lower Extremity - Evolent_CG_2032
  • CT Angiography, Lower Extremity - Evolent_CG_2033
  • MRA Lower Extremity - Evolent_CG_2034
  • MRI Lower Extremity, MRI Hip, MRI Pelvis - Evolent_CG_2035
  • CT Lumbar Spine - Evolent_CG_2036
  • MRI Lumbar Spine - Evolent_CG_2037
  • CT Soft Tissue Neck - Evolent_CG_2039
  • CT Angiography, Neck - Evolent_CG_2040
  • MRA Neck - Evolent_CG_2041
  • CT Pelvis - Evolent_CG_2042
  • CT Angiography, Pelvis - Evolent_CG_2043
  • MRA Pelvis - Evolent_CG_2044
  • MRI Pelvis - Evolent_CG_2045
  • CT Maxillofacial/Sinus - Evolent_CG_2047
  • MRI Orbit, Face, Neck and/or Internal Auditory Canal - Evolent_CG_2048
  • MRA Spinal Canal - Evolent_CG_2053
  • CT Orbit - Evolent_CG_2054
  • MRI Temporomandibular Joint - Evolent_CG_2055
  • CT Thoracic Spine - Evolent_CG_2056
  • MRI Thoracic Spine - Evolent_CG_2057
  • Unlisted Studies – Evolent_CG_2061
  • CT Upper Extremity - Evolent_CG_2062
  • CT Angiography, Upper Extremity - Evolent_CG_2063
  • MRA Upper Extremity - Evolent_CG_2064
  • MRI Upper Extremity Joint, MRI Upper Extremity, other than Joint - Evolent_CG_2065
  • Urgent/Emergent Criteria – Evolent_CG_2066
  • Place of Service Policy 2067 for Radiology – Evolent_CG_2067
  • CT Angiography, Head and Neck - Evolent_CG_2068
  • Fractional Flow Reserve Computed Tomography (CT) – Evolent_CG_7293
  • Heart PET Scan - Evolent_CG_7294
  • Heart PET with CT for Attenuation - Evolent_CG_7298
Updates to Clinical Guidelines
  • Coronary Artery Calcium Scoring by Electron Beam Computed Tomography (EBCT) or Non-Contrast Coronary Computed Tomography (CCT) – Evolent_CG_7272
  • Heart Computed Tomography (CT) Structure and Morphology, Congenital Studies – Evolent_CG_7296
  • Heart Magnetic Resonance Imaging (MRI) – Evolent_CG_7297
  • Myocardial Perfusion Imaging (MPI) – Evolent_CG_7312
  • Stress Echocardiogram – Evolent_CG_7328
  • Transthoracic Echocardiogram (TTE) – Evolent_CG_7337
  • Breast Magnetic Resonance Imaging (MRI) – Evolent_CG_2014
  • Magnetic Resonance Elastography (MRE) – Evolent_CG_2038
  • Positron Emission Tomography (PET) Scan, PET Scan with Computed Tomography (CT) for Attenuation – Evolent_CG_2046
  • Radiopharmaceutical Tumor Localization Single Proton Emission Computed Tomography (SPECT) – Evolent_CG_2052
Clinical Guidelines, Reviewed and Renewed for 2027
  • Multiple Gated Acquisition Scan (MUGA) – Evolent_CG_7311
  • Transesophageal Echocardiogram (TEE) – Evolent_CG_7336
  • CT (Virtual) Colonoscopy – Diagnostic - Evolent_CG_2022
  • Fetal Magnetic Resonance Imaging (MRI) - Evolent_CG_2027
  • Follow Up, Limited or Localized Computed Tomography (CT) — Evolent_CG_2029
  • Tumor Imaging Positron Emission Tomography (PET) Any Site, Breast Cancer, Melanoma — Evolent_CG_2058

Medicare Advantage and CHIP Radiation Oncology
Effective January 1, 2027
Updates to Clinical Guidelines
  • Radiation Therapy Services – Evolent_CG_7000
  • Proton Beam Radiation Therapy and Neutron Beam Radiation Therapy Services – Evolent_CG_7001

A link to Evolent's medical policies is available on Capital's Medical Policies web page.

Disclaimer: On behalf of Capital Blue Cross, Evolent Specialty Services, Inc. (Evolent), reviews certain medical specialty requests to see if they are medically necessary and a covered service under the Capital Blue Cross benefit plan. Evolent is an independent company.

Capital Blue Cross Medical Policy Updates and Preauthorization Requirements

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

KEY POINT: Effective January 1, 2027, TurningPoint will utilize updated medical policies in utilization management decisions for delegated MSK and Cardiology services.

TurningPoint’s medical policies and the delegated list of services have been reviewed and approved by Capital committees. The following medical policy updates will apply effective January 1, 2027.

Effective January 1, 2027
Commercial & Medicare Advantage Musculoskeletal Policies – New Policies
OR-1039 Thermal Intradiscal Procedures OR-1051 Implantable Shock Absorber
Commercial & Medicare Advantage Musculoskeletal Policies – Criteria Updates
OR-1001 Total Hip Replacement & Revision
OR-1002 Total Knee Replacement & Revision
OR-1003 Lumbar Disc Replacement
OR-1004 Lumbar Spinal Fusion
OR-1006 Cervical Disc Replacement
OR-1007 Cervical Laminectomy and Discectomy
OR-1008 Lumbar Laminectomy, Discectomy, and Laminectomy
OR-1009 Sacroiliac Joint Fusion
OR-1010 Thoracic Laminectomy and Discectomy
OR-1011 Thoracic Spinal Fusion
OR-1012 Cervical Spinal Fusion
OR-1013 ACL Repair
OR-1014 Treatment of Osteochondral Defect
OR-1015 Spinal Cord Stimulator
OR-1018 Acromioplasty & Rotator Cuff Repair
OR-1019 Shoulder Fusion
OR-1020 Surgery for Spinal Deformity		 OR-1021 Ankle Replacement & Revision
OR-1023 Shoulder Replacement
OR-1024 Vertebral Augmentation
OR-1027 Meniscal Allograft Transplantation
OR-1028 Partial Knee Replacement
OR-1029 Knee Arthroscopy
OR-1030 Ankle Fusion
OR-1031 Hip Arthroscopy
OR-1032 Wrist Fusion
OR-1033 Wrist Replacement
OR-1034 Implantable Infusion Pumps
OR-1035 Computer Assisted Navigation
OR-1036 Shoulder Procedures
OR-1037 Spinal Devices
OR-1038 Sacral Decompression
OR-1040 Manipulation Under Anesthesia
OR-1046 Bone Graft Substitutes
OR-1049 Percutaneous Tenotomy
Commercial & Medicare Advantage Musculoskeletal Policies- Reviewed and Renewed for 2027
OR-1022 Elbow Replacement
OR-1042 Hip Osteotomy
OR-1043 MPFL Reconstruction
OR-1045 Osteotomies for Spinal Deformity		 OR-1047 Orthopedic Application of Stem Cell Therapy
OR-1050 Hip Core Decompression
GN-1001 Assistants at Surgery
Commercial & Medicare Advantage Musculoskeletal Policies – Retirements
OR-1005 Bone Morphogenetic Protein
Commercial & Medicare Advantage Cardiovascular Policies – Criteria Updates
CA-1001 Implantable Cardioverter Defibrillator
CA-1003 Pacemaker
CA-1005 Coronary Artery Bypass Grafting
CA-1006 Coronary Angioplasty and Stenting
CA-1007 Non-Coronary Angioplasty and Stenting
CA-1008 Implantable Cardiac Monitoring
CA-1009 Wearable Cardioverter Defibrillator
CA-1010 Percutaneous Left Atrial Appendage Occluder		 CA-1011 Valve Replacement
CA-1013 Diagnostic Coronary Angiography
CA-1019 Peripheral Diagnostic Angiogram & Venogram
CA-1020 Cardiac Ablation
CA-1021 Percutaneous Transcatheter Cardiac Defect Closure
Commercial & Medicare Advantage Cardiology Policies – Reviewed and Renewed for 2027
CA-1018 Cardiac Contractility Modulation
Commercial & Medicare Advantage Cardiovascular Policies – Retirements
CA-1012 Peripheral Revascularization

A link to TurningPoint's medical policies is available on Capital's Medical Policies web page. A complete list of CPT/HCPCS codes requiring preauthorization can be found on Capital's Single Source Preauthorization List.

Disclaimer: On behalf of Capital Blue Cross, TurningPoint Healthcare Solutions LLC assists in the administration of our musculoskeletal benefits program and/or cardiac authorization program(s). TurningPoint Healthcare Solutions LLC is an independent company.