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Medical Policy and Coding Updates - September 2022
Premera Blue Cross·WA, AK · Orthopedics, Gastroenterology, Rheumatology +7 more·Medical Policy
Effective date
Dec 1, 2022
We identified it
Jun 18, 2026
Summary
This comprehensive policy update includes multiple medical necessity criteria changes, site of service updates, and clinical guidelines revisions affecting various specialties. Key changes include updated drug criteria for gout and IBD treatments, revised imaging guidelines for orthopedic and spine conditions, expanded genetic testing criteria, and modified surgical requirements for spine and GYN procedures.
Action Required
By December 1, 2022: Billing team must update prior authorization requirements for Krystexxa (pegloticase) to include mandatory weekly methotrexate 15mg unless contraindicated, and Tysabri (natalizumab) to require documentation of TNF blocker failure. By November 4, 2022: Update site of service requirements for Cutaquig to infusion center only. By September 11, 2022: Review and update imaging authorization criteria for extremity, spine, and vascular imaging per AIM Specialty Health guidelines - notably rotator cuff conservative management increased from 4 to 6 weeks. By September 2, 2022: Update cervical spine fusion criteria to require 12-month imaging for pseudoarthritis and add hardware failure as revision indication.