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Medical Policy and Coding Updates - July 2019
Premera Blue Cross·WA · Orthopedics, Cardiology, ENT (Ear, Nose & Throat) +8 more·Medical Policy
Effective date
Jul 1, 2019
We identified it
Jun 18, 2026
Summary
Multiple policy updates effective at different dates including new joint replacement Centers of Excellence requirements (Jan 2020), updated imaging guidelines for cardiac, head/neck, oncologic and vascular procedures (Nov 2019), new drug coverage criteria for osteoporosis medications (Aug 2019), and revised coverage for artificial pancreas systems, spinal procedures, and breast implant removal (July 2019).
Action Required
By January 1, 2020: Billing team must verify network participation in Total Joint Replacement Centers of Excellence Program for knee/hip replacement coverage. By November 10, 2019: Update prior authorization processes for advanced imaging following new AIM Specialty Health guidelines - cardiac imaging post-transplant, head/neck imaging for sinusitis, oncologic PET-CT scans, and vascular imaging protocols now have revised criteria. By August 2, 2019: Update pharmacy prior authorization for Evenity (romosozumab-aqqg) and revised Tymlos criteria. Immediately: Review artificial pancreas device coverage criteria, intraoperative monitoring requirements, breast implant removal for lymphoma cases, and dorsal root ganglion stimulation trials.