Medicare AdvantagePrior AuthHigh impact
Medical policy updates
Blue Cross Blue Shield of Rhode Island·Psychiatry, Oncology, Urology +1 more·Provider Update
Effective date
Jul 1, 2025
We identified it
Jun 19, 2026
Summary
Multiple medical policy changes affecting genetic testing, behavioral health, and cancer diagnostics with new prior authorization requirements and coverage changes. Many genetic testing codes are removing prior auth requirements while others are moving to online authorization tools with new medical criteria.
Action Required
By July 1, 2025: Update billing system to remove prior authorization for CPT codes 81175, 81176, 0402U, 0455U, 0248U, and 0435U. Add prior authorization requirements for CPT 81162 for commercial plans when not filed with specified diagnosis codes. By September 1, 2025: Add TMS coverage restrictions requiring covered ICD-10 codes, update prior authorization workflows for genetic testing codes moving to online authorization tools, and implement new medical criteria for prostate cancer testing. Billing team must verify ICD-10 codes Z13.79 and Z14.1 are linked to genetic testing claims to avoid authorization requirements.