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Medical Policy and Coding Updates - October 2021

Premera Blue Cross·WA · Orthopedics, Neurosurgery, OB-GYN +2 more·Medical Policy
Effective date
Jan 7, 2022
We identified it
Jun 18, 2026
Days to comply

Summary

Major policy updates affecting multiple surgical specialties with new prior authorization requirements for site of service review and medical necessity criteria updates. Key changes include new site-of-service reviews for single-level cervical and lumbar spine surgeries, new hysterectomy policy for non-malignant conditions, and multiple new drug approvals across oncology and other therapeutic areas.

Action Required

Action needed
By January 7, 2022: Billing team must update system to require site-of-service review for medical necessity for CPT codes 22533, 22551, 22554, 22558, 22600, 22612, 22630, 22633, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294, 58550, 58552, 58553, 58554, 63020, 63045. Update encounter forms to remind providers of new hysterectomy policy requirements and spine surgery site-of-service criteria. Remove HCPCS code C1726 from billing system. By December 2, 2021: Update drug formulary for new Arcalyst coverage. By November 5, 2021: Mark allograft injection for degenerative disc disease as investigational.

Affected Billing Codes

22533
22551
22554
22558
22600
22612
22630
22633
58260
58262
58263
58267
58270
58275
58280
58290
58291
58292
58294
58550
58552
58553
58554
63020
63045
Q4251
Q4252
Q4253
C9084
Q2054
C9081
19105