Boletín administrativo: 2026-02-003 Medical policies

Date: February 1, 2026

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

Topics covered in this administrative bulletin are applicable to:

Proveedores profesionales y de centros

Professional and facility providers

Notificación de políticas médicas nuevas y revisadas y requisitos de autorización previa

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.

Nombre de la política
Acción
Fecha de entrada en vigencia
Highlights

Blenrep

Nuevo

4/1/2026

J9999 will now require PA for new drug Blenrep

Omvoh®

Revised

4/1/2026

See updated policy for details.

Vyvgart® SQ

Revised

4/1/2026

See updated policy for details

Besponsa™

Revised

4/1/2026

See updated policy for details

Bevacizumab

Revised

4/1/2026

See updated policy for details.

Botox®

Revised

4/1/2026

See updated policy for details.

Briumvi®

Revised

4/1/2026

See updated policy for details.

Columvi®

Revised

4/1/2026

See updated policy for details.

Darzalex® SQ

Revised

4/1/2026

See updated policy for details.

Daxxify®

Revised

4/1/2026

See updated policy for details.

Dysport®

Revised

4/1/2026

See updated policy for details.

Epkinly®

Revised

4/1/2026

See updated policy for details.

Gazyva®

Revised

4/1/2026

See updated policy for details.

Kebilidi™

Revised

4/1/2026

See updated policy for details.

Lemtrada®

Revised

4/1/2026

See updated policy for details.

Monjuvi®

Revised

4/1/2026

See updated policy for details.

Myobloc®

Revised

4/1/2026

See updated policy for details.

Natalizumab

Revised

4/1/2026

See updated policy for details.

Ocrevus® IV

Revised

4/1/2026

See updated policy for details.

Ocrevus® SQ

Revised

4/1/2026

See updated policy for details.

Oncaspar®

Revised

4/1/2026

See updated policy for details.

Opdivo™ SQ

Revised

4/1/2026

See updated policy for details.

Paclitaxel Albumin-Bound

Revised

4/1/2026

See updated policy for details.

Pemetrexed

Revised

4/1/2026

See updated policy for details.

Rylaze®

Revised

4/1/2026

See updated policy for details.

Trastuzumab IV

Revised

4/1/2026

See updated policy for details.

Vyepti®

Revised

4/1/2026

See updated policy for details.

Vyvgart® IV

Revised

4/1/2026

See updated policy for details.

Xeomin®

Revised

4/1/2026

See updated policy for details.

Zynlonta®

Revised

4/1/2026

See updated policy for details.

Zynteglo®

Revised

4/1/2026

See updated policy for details.

Encelto™

Revised

4/1/2026

See updated policy for details.

Commercial effective 3/1/2026

Abbreviations: E/I – Experimental/investigational; INV – Investigational; MN – Medically Necessary; MP – Medical Policy; NMN – Not Medically Necessary; PA – Preauthorization
Nombre de la política
Número de la política
Acción
Highlights

Hospital Beds and Accessories

6.001

Revised

Change in title; formerly hospital beds, accessories and pressure reducing surfaces.

Removed detailed criteria for pressure reducing surfaces, these remain MN in the general list of accessories.

Knee Braces (Rodilleras)

6.012

Revised

Procedure codes L1834, L1840, and L1846 will no longer require PA, as these procedure codes are INV.

Commercial effective 4/1/2026

Abbreviations: E/I – Experimental/investigational; INV – Investigational; MN – Medically Necessary; MP – Medical Policy; NMN – Not Medically Necessary; PA – Preauthorization
Nombre de la política
Número de la política
Acción
Highlights

Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer (Biomarcadores genéticos y de proteínas para el diagnóstico y la evaluación del riesgo de cáncer de próstata)

2.280

Revised

Change in title; formerly Gene Expression Profiling and Protein Biomarkers for the Management, Diagnosis, and Cancer Risk Assessment of Prostate Cancer.

Prostate cancer management tests and associated procedure codes have been removed and placed on MP 2.263 as INV.

Diagnosis and Treatment of Sacroiliac Joint Pain (Diagnóstico y tratamiento del dolor de la articulación sacroilíaca)

5.048

Revised

Updated criteria, no more than three (3) injections are given within a twelve (12) month period.

Added procedure codes 64640 and 64451.

Removed procedure code 64635.

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

2.263

Reinstated

Policy reinstated.

Indications are INV, were previously MN on MP 2.280.

Reconstructive Breast Surgery Including Management of Breast Implants, External Breast Prosthesis

1.103

Revised

Removed lymphedema sleeve language and associated procedure code (L8010).

Clarified language to specify coverage for one (1) off-the-shelf and one (1) custom-fabricated breast prosthesis per affected side.

Defined the twelve-month (12) period as a rolling twelve (12) months.

Defined "useful lifetime".

Medicare Advantage and 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
Nombre de la política
Número de la política
Acción
Highlights

Experimental and Investigational Procedures (Procedimientos experimentales y de investigación)

4.002

Revised

Removed procedure code 0707T.

Procedure code 0707T will now require PA.

Removed procedure codes; 0338T, 0339T, 0935T, C1735, C1736 will no longer require PA for MA.

Celiac Disease Testing (Prueba de la enfermedad celíaca)

G2043 Avalon

Revised

Removed criteria related to genetic testing.

Pathogen Panel Testing (Pruebas de panel de patógenos)

G2149 Avalon

Revised

Updated criteria for individuals who are immunocompromised and who are displaying signs and symptoms of a respiratory tract infection (see Note 1), multiplex polymerase chain reaction (PCR)-based panel testing of up to twenty-five (25) respiratory pathogens.

Added procedure codes 0590U and 0593U.

Testing for Vector-Borne Infections (Pruebas de infecciones transmitidas por vectores)

G2158 Avalon

Revised

Updated criteria, for individuals suspected of having babesiosis, the use of Immunoglobulin G (IgG) or Immunoglobulin M (IgM) indirect immunofluorescence antibody (IFA) assay for Babesia now meets coverage criteria.

Added procedure codes 87164 and 87166.

Bone Turnover Markers Testing (Prueba de marcadores de recuperación de la densidad ósea)

G2051 Avalon

Annual Review.

Administrative and/or formatting changes without a change in coverage or criteria may have been made to these policies.

Diabetes Mellitus Testing (Pruebas de diabetes mellitus)

G2006 Avalon

Diagnostic Testing of Influenza (Pruebas de diagnóstico de la influenza)

G2119 Avalon

Citología de células epiteliales en la evaluación del riesgo de cáncer de mama

G2059 Avalon

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

G2060 Avalon

Fecal Calprotectin Testing (Prueba de calprotectina fecal)

G2061 Avalon

Gamma Glutamyl Transferase (GGT)

G2173 Avalon

Análisis de muestra de biopsia de próstata

G2007 Avalon

Urine Culture Testing for Bacteria (Prueba de cultivo de orina para detectar bacterias)

G2156 Avalon

Medicare Advantage and Commercial effective 4/1/2026

Abbreviations: E/I – Experimental/investigational; INV – Investigational; MA – Medicare Advantage; MN – Medically Necessary; MP – Medical Policy; NMN – Not Medically Necessary; PA – Preauthorization
Nombre de la política
Número de la política
Acción
Highlights

Biomarkers Testing for Multiple Sclerosis and Related Neurologic Diseases

G2123 Avalon

Revised

Change in title; formerly Serum Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases.

Gender Affirming Surgery (Cirugía de afirmación de género)

1.144

Revised

Procedure codes: 54125, 55970, 55980, 56805, 57110, 57292, and 57335 will now require PA.

Added procedure codes 15769 and 55866.

Removed procedure codes: 19328, 30460, 30462, 52281, 52285, 54120, 54130, 54135, 54308, 54312, 54316, 54318, and 57109.

Diagnosis of Vaginitis

M2057 Avalon

Revised

Removed criteria for nucleic acid amplification testing (NAAT) and polymerase chain reaction-based identification for Trichomonas vaginalis.

Specified that broad molecular panels that concurrently test vaginalis and Sexually Transmitted Infections (STIs) do not meet coverage criteria.

In Vitro Chemoresistance and Chemosensitivity Assays (Ensayos de quimiorresistencia y quimiosensibilidad in vitro)

G2100 Avalon

Annual Review.

Administrative and/or formatting changes without a change in coverage or criteria may have been made to this policy.

Examen de diagnóstico y pruebas de cáncer bucal

G2113 Avalon

Revised

Added “or with metastatic squamous cell carcinoma of unknown primary origin in a cervical lymph node” to coverage criteria.

Added new criteria, "Detection of Human Papillomavirus (HPV) from an oropharyngeal swab (e.g., OmniPathology Oropharyngeal HPV Polymerase Chain Reaction (PCR) Test) does not meet coverage criteria."

Testing for Diagnosis of Active or Latent Tuberculosis (Pruebas para el diagnóstico de tuberculosis activa o latente)

G2063 Avalon

Revised

Removed criteria speaking to direct or amplified probe nucleic acid based testing.

Revised criteria statement for suspected Tuberculosis infections, added that qualitative nucleic acid amplification testing (NAAT) for Mycobacteria spp., mycobacterium tuberculosis, and mycobacterium avium complex testing meets coverage criteria.

Replaced "Hologic Amplified Mycobacterium Tuberculosis Direct" with "NAAT" for clarity.

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
Nombre de la política
Número de la política
Highlights

Radiofrequency Ablation of Primary or Metastatic Liver Tumors (Ablación por radiofrecuencia de tumores hepáticos metastásicos o primarios)

1.055

Retirement.

Procedure codes 47370 and 47380 will be removed from PA.

BCR ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia (Pruebas BCR ABL1 para la leucemia mieloide crónica y la leucemia linfoblástica aguda)

2.317

Retirement.

Biofeedback and Neurofeedback Therapy (Terapia de biorretroalimentación y neurorretroalimentación)

2.064

Retirement.

Refer to Local Coverage Determination (LCD) or to the National Coverage Determination (NCD).

Endomicroscopia confocal con láser

2.093

Retirement.

Procedure codes 0397T and 88375 have been removed and placed on MA 4.002.

Refer to LCD or to the NCD.

Corneal Surgery Implantation of Intrastromal Corneal Ring Segment and Corneal Topography/Photokeratoscopy (Implante corneal quirúrgico de segmentos de anillos corneales intraestromales y topografía corneal/fotoqueratoscopía)

1.044

Retirement.

Intraocular Lenses, Spectacle Correction, and Iris Prosthesis (Lentes intraoculares, corrección de gafas y prótesis de iris)

6.058

Retirement.

Refer to LCD or to the NCD.

Endovascular Grafts for Abdominal Aortic Aneurysms (Injertos endovasculares para aneurismas de la aorta abdominal)

1.090

Retirement.

Refer to LCD or to the NCD.

Genetic and Protein Biomarkers for the Management Diagnosis and Cancer Risk Assessment of Prostate Cancer (Biomarcadores genéticos y de proteínas para la gestión del diagnóstico y la evaluación del riesgo de cáncer de próstata)

2.280

Retirement.

Procedure codes: 0021U, 0359U, 0376U, 0513U, and 0550U have been removed and placed on MA 2.277.

Refer to LCD or to the NCD.

General Approach to Genetic Testing (Enfoque general sobre la prueba genética)

2.326

Retirement.

Genetic Testing for Duchenne and Becker Muscular Dystrophy (Prueba genética de las distrofias musculares de Duchenne y Becker)

2.257

Retirement.

Refer to LCD or to the NCD.

Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes (Prueba genética para el síndrome de Lynch y otros síndromes de cáncer de colon hereditario)

5.013

Retirement.

Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies (Pruebas genéticas para el diagnóstico de neuropatías periféricas hereditarias)

2.355

Retirement.

Refer to LCD or to the NCD.

JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms (Pruebas JAK2, MPL y CALR para neoplasias mieloproliferativas)

2.281

Retirement.

Refer to LCD or to the NCD.

Pharmacogenomic and Metabolite Markers for Patients with Inflammatory Bowel Disease Treated with Thiopurines​​​​​​​ (Marcadores farmacogenómicos y de metabolitos para pacientes con enfermedad inflamatoria intestinal tratados con tiopurinas)

2.218

Retirement.

Pruebas de biomarcadores somáticos (incluida la biopsia líquida) para el tratamiento dirigido en el cáncer colorrectal metastásico

2.316

Retirement.

Somatic Genetic Testing to Select Individuals with Melanoma or Glioma for Targeted Therapy or Immunotherapy (Pruebas genéticas somáticas para seleccionar personas con melanoma o glioma para terapia dirigida o inmunoterapia)

2.364

Retirement.

Cirugía para el dolor inguinal en atletas

1.163

Retirement.

Total Artificial Hearts and Implantable Ventricular Assist Devices (Corazones totalmente artificiales y dispositivos de asistencia ventricular implantables)

1.026

Retirement.

Refer to LCD or to the NCD.