All PlansPrior AuthHigh impact
Medical Policy and Coding Updates - April 2019
Premera Blue Cross·WA · Oncology, Rheumatology, Gastroenterology +2 more·Medical Policy
Effective date
Apr 1, 2019
We identified it
Jun 18, 2026
Summary
Multiple policy changes affecting various specialties with new prior authorization requirements for several injection codes, coverage updates for oncology drugs and medical devices, and revised criteria for specialty medications. Key changes include new prior auth requirements for durvalumab injections, gemtuzumab ozogamicin, and penis correction procedures, plus updated criteria for arthritis and IBD medications.
Action Required
By April 1, 2019: Billing team must update system to require prior authorization for codes J9203 (gemtuzumab ozogamicin), J9173 (durvalumab), and 54360 (penis angulation correction). Update encounter forms and billing software rules. Review and implement new medical necessity criteria for infliximab products including dose frequency requirements. Verify prior auth processes are in place to prevent claim denials.