All Insurance Policy Changes (Page 91)

Continuing from page 90. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

High impact
Spinal Cord Stimulation / Dorsal Column Stimulation - (Effective Date - 2026-10-15) 7.01.51
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has issued a comprehensive new medical policy (7.01.51) effective October 15, 2026, establishing specific coverage criteria for spinal cord stimulation (SCS) and dorsal column stimulation devices across five clinical indications: Failed Back Surgery Syndrome, Painful Diabetic Peripheral Neuropathy, Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy, Chronic Critical Limb Ischemia, and Chronic Stable Angina Pectoris. The policy mandates strict pre-implantation requirements including conservative treatment failure, behavioral health clearance, and successful trial outcomes (≥50% pain relief) before permanent device placement.
High impact
Spinal Cord Stimulation / Dorsal Column Stimulation 7.01.51
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield has released a comprehensive new policy (7.01.51, effective Oct 15, 2025) establishing strict medical necessity criteria for spinal cord stimulation (SCS) and dorsal column stimulation procedures across five clinical indications: Failed Back Surgery Syndrome, Complex Regional Pain Syndrome, Chronic Critical Limb Ischemia, Chronic Stable Angina, and device replacements. All trials now require >48 hours duration, 6+ months of conservative management, behavioral health clearance, and permanent implants require ≥50% pain reduction during trial. High-frequency to high-frequency upgrades are explicitly non-covered.
High impact
Shoulder Arthroplasty (Total, Partial, Reverse, Revision and Resurfacing) 7.01.95
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield has issued a comprehensive new medical policy (7.01.95, effective October 15, 2025) establishing specific clinical criteria and medical necessity requirements for shoulder arthroplasty procedures including total, partial (hemi), reverse, and revision surgeries. The policy defines exact diagnostic, functional, and conservative treatment prerequisites that must be met before authorization; procedures not meeting these criteria or performed on patients with contraindications (active infection, paralytic disorders, uncontrolled medical conditions, Charcot joint) will be considered not medically necessary and denied. Shoulder resurfacing is classified as investigational.
High impact
Shoulder Arthroplasty (Total, Partial, Reverse, Revision and Resurfacing) - (Effective Date - 2026-10-15) 7.01.95
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has released a comprehensive shoulder arthroplasty policy (7.01.95) effective October 15, 2026, establishing specific medical necessity criteria for total shoulder replacement, hemi-arthroplasty, reverse total arthroplasty, revision procedures, and classifying shoulder resurfacing as investigational. This policy replaces prior guidance and requires strict documentation of radiographic findings, function-limiting pain duration (3-6 months depending on procedure type), and failed conservative management before coverage approval.
Medium impact
Sacroiliac Joint Fusion or Stabilization 7.01.93
Excellus BlueCross BlueShield·Identified Jul 16, 2026
Failed to analyze policy change
High impact
Sacroiliac Joint Fusion or Stabilization - (Effective Date - 2026-10-15) 7.01.93
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield released a comprehensive new policy (effective October 15, 2026) establishing strict medical necessity criteria for sacroiliac joint (SIJ) fusion and stabilization procedures. The policy requires extensive pre-operative documentation including dual diagnostic SIJ blocks with ≥75% pain reduction, 6+ months of conservative treatment, nicotine-free status verification, mental health clearance, and specific physical examination findings. Open SIJ fusion is limited to post-traumatic injury, infection management, tumor cases, spinal deformity correction, or failed prior percutaneous fusion. Prior authorization will be required for all non-emergency cases.
High impact
Radiofrequency Facet and Sacroiliac Joint Ablation/ Denervation - (Effective Date - 2026-10-15) 7.01.42
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has issued a comprehensive new policy (effective October 15, 2026) establishing strict medical necessity criteria for radiofrequency facet joint ablation/denervation procedures. The policy requires prior authorization documentation including: 3+ months of pain, 4+ weeks of conservative treatment, two sequential diagnostic blocks with ≥80% relief, CT/fluoroscopic guidance, and limits on frequency (max 2 per 12 months at same level, minimum 6 months apart). Multiple advanced techniques (pulsed RF, cryoablation, cooled RF, sacroiliac denervation) are classified as investigational and not covered. Sacroiliac joint radiofrequency denervation is explicitly not medically necessary.
High impact
Radiofrequency Facet and Sacroiliac Joint Ablation/ Denervation 7.01.42
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield issued a new policy (7.01.42) effective October 15, 2025, establishing comprehensive coverage criteria for radiofrequency facet and sacroiliac joint ablation/denervation procedures. The policy requires strict documentation of conservative treatment failure, two sequential diagnostic blocks with 80% pain relief, CT/fluoroscopic guidance, and prohibits multiple procedures within rolling 12-month periods. Several alternative techniques (pulsed RF, cryoablation, cooled RF, and sacroiliac joint ablation) are classified as investigational and non-covered.
Medium impact
Prolotherapy 8.01.10
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield has classified Prolotherapy (8.01.10) as investigational for treating musculoskeletal pain and instability, effective October 15, 2025. This means prolotherapy procedures will not be covered and claims will be denied unless the member's contract specifically includes coverage for investigational services. Billing teams must implement denial protocols and update systems to route prolotherapy claims appropriately.
High impact
Prolotherapy - (Effective Date - 2026-10-15) 8.01.10
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has classified Prolotherapy as an investigational treatment for musculoskeletal pain and instability effective October 15, 2026. This means prolotherapy procedures will not be covered as they do not meet medical necessity criteria. Billing teams must implement denial protocols and ensure providers are informed to avoid claim rejections.
High impact
Positron Emission Tomography (PET) Oncologic Applications 6.01.29
Excellus BlueCross BlueShield·Effective May 15, 2026
Excellus BlueCross BlueShield has updated its PET Oncologic Applications policy (6.01.29) effective May 15, 2026, establishing new medical necessity criteria for FDG-PET and PET/CT imaging across 25+ cancer types. The policy defines when PET imaging is appropriate for initial staging, restaging/recurrence, and surveillance, with specific clinical criteria for each cancer type. Billing teams must align claim submission and prior authorization processes to match these detailed eligibility requirements by the effective date.
High impact
Positron Emission Tomography (PET) Oncologic Applications - (Effective Date - 2026-10-15) 6.01.29
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has issued a comprehensive PET oncologic applications policy (effective October 15, 2026) that establishes medical necessity criteria for FDG PET/CT imaging across 30+ cancer types. The policy specifies when PET imaging is covered for initial staging, restaging/recurrence, and surveillance, with notably restrictive guidance on surveillance imaging for most cancers and specific requirements for documentation of clinical scenarios (e.g., inconclusive conventional imaging, isolated metastatic lesions amenable to surgical resection). Billing teams must update authorization workflows and documentation requirements to align with these cancer-specific criteria.
High impact
Positron Emission Tomography (PET) - Non-Oncologic Applications 6.01.07
Excellus BlueCross BlueShield·Effective May 15, 2026
Excellus BlueCross BlueShield has established a comprehensive medical policy for PET imaging in non-oncologic applications, effective May 15, 2026. This policy defines specific clinical criteria and appropriate use for PET/CT imaging across multiple body systems (abdominal, cardiac, chest, musculoskeletal, spine, and vascular) while designating certain uses as not medically appropriate or investigational. Billing teams must ensure prior authorization requests and claims align with the detailed indication-specific criteria outlined in this policy.
High impact
Positron Emission Tomography (PET) - Non-Oncologic Applications - (Effective Date - 2026-10-15) 6.01.07
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has issued a comprehensive new medical policy (effective October 15, 2026) establishing coverage criteria for PET imaging in non-oncologic applications, including abdominal imaging, cardiac imaging, prosthetic valve endocarditis assessment, and LVAD infections. This policy requires strict adherence to specific clinical indications and documentation requirements for coverage eligibility. Billing teams must implement prior authorization protocols and ensure provider documentation aligns with the detailed medical necessity criteria outlined.
High impact
Positive Airway Pressure Devices CPAP BiPAP APAP and Noninvasive Positive Pressure Ventilators (NIV) 1.01.06
Excellus BlueCross BlueShield·Effective Jul 17, 2025
Excellus BlueCross BlueShield has issued a comprehensive update to its policy on Positive Airway Pressure (PAP) devices covering CPAP, APAP, BPAP, and NIPPV effective July 17, 2025. The policy establishes new clinical criteria for initial 90-day trials, continuation coverage requirements (70% nightly use, 4+ hours per 24-hour period), device replacement standards, and specific indications for each device type. Billing teams must verify medical necessity documentation, compliance metrics, and device failure justification before processing claims for these sleep medicine devices.
High impact
Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty - (Effective Date - 2026-10-15) 6.01.17
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has updated its vertebroplasty/kyphoplasty policy (effective October 15, 2026) with stricter medical necessity criteria for non-malignant conditions, requiring 4 weeks of conservative treatment before approval and enrollment in osteoporosis programs. Sacroplasty is now classified as investigational for all indications. The policy establishes clear contraindications and limits coverage to specific spine levels (T5-L5) with maximum 2 levels per date of service.
High impact
Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty 6.01.17
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield updated its vertebroplasty/kyphoplasty and sacroplasty policy (6.01.17) effective October 15, 2025, with stricter medical necessity criteria requiring prior authorization, comprehensive documentation of failed conservative treatment (4+ weeks), and limiting coverage to T5-L5 spine at maximum 2 levels per date of service. Sacroplasty is now classified as investigational for all indications, and percutaneous vertebroplasty will NOT be separately reimbursed when combined with open spine procedures.
High impact
Osteochondral Grafting of the Knee - (Effective Date - 2026-10-15) 7.01.59
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has established strict medical necessity criteria for osteochondral grafting (OATS/mosaicplasty) of the knee, effective October 15, 2026. Coverage requires patients to meet 10 specific criteria including BMI <35, age ≤49 years, Kellgren-Lawrence Grade II or less, specific defect sizes, failed conservative management for 3+ months, and stable knee anatomy. Hybrid ACI/OATS procedures are deemed investigational and not covered.
High impact
Osteochondral Grafting of the Knee 7.01.59
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield established a new medical policy (effective October 15, 2025) establishing strict coverage criteria for osteochondral grafting procedures of the knee. The policy defines when OATS/mosaicplasty/allograft transplantation is medically appropriate, requiring meeting ALL criteria including BMI <35, age ≤49, specific imaging findings, defect size limits, and 3+ months of failed conservative management. Any procedures outside these criteria or using hybrid ACI/OATS techniques are considered investigational and non-covered.
High impact
Metal-on-Metal Total Hip Resurfacing 7.01.74
Excellus BlueCross BlueShield·Effective Oct 15, 2025
Excellus BlueCross BlueShield has issued a new medical policy (7.01.74, effective October 15, 2025) establishing specific coverage criteria for metal-on-metal total hip resurfacing. The procedure is now covered only for patients age 64 or younger who meet strict imaging, symptom, and conservative treatment failure requirements. Claims not meeting ALL criteria will be denied as not medically necessary.
High impact
Metal-on-Metal Total Hip Resurfacing - (Effective Date - 2026-10-15) 7.01.74
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has issued a new medical policy (7.01.74, effective October 15, 2026) establishing coverage criteria for metal-on-metal total hip resurfacing in patients age 64 and younger. The policy requires strict documentation of medical necessity, including imaging findings, function-limiting symptoms lasting 3+ months, failed conservative management, and excludes patients with specific contraindications (metal sensitivity, childbearing potential, dialysis patients, >50% femoral head involvement, and others). Billing teams must implement prior authorization requirements and documentation validation before claims submission.
Medium impact
Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD) 7.01.89
Excellus BlueCross BlueShield·Effective Apr 17, 2025
Excellus BlueCross BlueShield has established a new coverage policy for Magnetic Sphincter Augmentation (LINX device) for GERD treatment, effective April 17, 2025. The policy is considered medically appropriate when strict clinical criteria are met, including age 18+, documented chronic GERD inadequately controlled by PPIs for 6+ months, physician training requirements, and multiple contraindications must be absent. Billing teams must implement prior authorization requirements and ensure providers meet all documented eligibility criteria before claim submission.
Medium impact
Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD) - (Effective Date - 2026-10-15) 7.01.89
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has established coverage criteria for Magnetic Sphincter Augmentation (LINX system) for GERD treatment effective October 15, 2026. MSA is now considered medically appropriate when specific clinical criteria are met, including age 18+, BMI <35, documented pathologic acid exposure, failure of 6+ months of optimized PPI therapy, and absence of contraindications. All other uses remain investigational.
High impact
Magnetic Resonance Imaging (MRI) of the Prostate 6.01.46
Excellus BlueCross BlueShield·Effective May 15, 2026
Excellus BlueCross BlueShield has released a comprehensive new policy (6.01.46, effective May 15, 2026) establishing detailed medical necessity criteria for prostate MRI across five clinical scenarios: suspected prostate cancer, initial work-up/staging, restaging/recurrence, and active surveillance follow-up. The policy introduces specific age, PSA, risk stratification, and clinical history requirements that must be met for coverage. Notably, serial MRIs for monitoring elevated PSA alone are NOT medically necessary, and MR guidance for needle placement is not covered.
High impact
Magnetic Resonance Imaging (MRI) of the Prostate - (Effective Date - 2026-10-15) 6.01.46
Excellus BlueCross BlueShield·Effective Oct 15, 2026
Excellus BlueCross BlueShield has issued a comprehensive new medical policy (6.01.46) effective October 15, 2026, establishing detailed coverage criteria for prostate MRI across five clinical scenarios: suspected prostate cancer, initial workup/staging, restaging/recurrence, and active surveillance follow-up. The policy specifies strict age and PSA thresholds, risk stratification requirements, and explicitly states that serial MRIs for PSA monitoring alone and MR guidance for needle placement are NOT medically necessary. Billing teams must implement prior authorization requirements based on these specific clinical criteria to avoid claim denials.

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2023 2024 2025 2026

Insurance Policy Changes Tracker: All Payer Updates (Page 91) | PolicyChanges.app

Spinal Cord Stimulation / Dorsal Column Stimulation - (Effective Date - 2026-10-15) 7.01.51

Spinal Cord Stimulation / Dorsal Column Stimulation 7.01.51

Shoulder Arthroplasty (Total, Partial, Reverse, Revision and Resurfacing) 7.01.95

Shoulder Arthroplasty (Total, Partial, Reverse, Revision and Resurfacing) - (Effective Date - 2026-10-15) 7.01.95

Sacroiliac Joint Fusion or Stabilization 7.01.93

Sacroiliac Joint Fusion or Stabilization - (Effective Date - 2026-10-15) 7.01.93

Radiofrequency Facet and Sacroiliac Joint Ablation/ Denervation - (Effective Date - 2026-10-15) 7.01.42

Radiofrequency Facet and Sacroiliac Joint Ablation/ Denervation 7.01.42

Prolotherapy 8.01.10

Prolotherapy - (Effective Date - 2026-10-15) 8.01.10

Positron Emission Tomography (PET) Oncologic Applications 6.01.29

Positron Emission Tomography (PET) Oncologic Applications - (Effective Date - 2026-10-15) 6.01.29

Positron Emission Tomography (PET) - Non-Oncologic Applications 6.01.07

Positron Emission Tomography (PET) - Non-Oncologic Applications - (Effective Date - 2026-10-15) 6.01.07

Positive Airway Pressure Devices CPAP BiPAP APAP and Noninvasive Positive Pressure Ventilators (NIV) 1.01.06

Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty - (Effective Date - 2026-10-15) 6.01.17

Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty 6.01.17

Osteochondral Grafting of the Knee - (Effective Date - 2026-10-15) 7.01.59

Osteochondral Grafting of the Knee 7.01.59

Metal-on-Metal Total Hip Resurfacing 7.01.74

Metal-on-Metal Total Hip Resurfacing - (Effective Date - 2026-10-15) 7.01.74

Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD) 7.01.89

Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD) - (Effective Date - 2026-10-15) 7.01.89

Magnetic Resonance Imaging (MRI) of the Prostate 6.01.46

Magnetic Resonance Imaging (MRI) of the Prostate - (Effective Date - 2026-10-15) 6.01.46