Medicare AdvantagePrior AuthHigh impact
Policy updates
Blue Cross Blue Shield of Rhode Island·RI · Plastic Surgery, Oncology, Physical Therapy +3 more·Physician / Facility
Effective date
May 1, 2024
We identified it
Jun 19, 2026
Summary
Multiple policy updates effective between January 1-May 1, 2024 affecting various services including breast reconstruction, genetic testing, PT/OT services, and fertility coverage. Key changes include removal of prior authorization for CPT 11971 breast reconstruction, elimination of ordering physician requirement for PT/OT, and coverage updates for genetic testing codes.
Action Required
By May 1, 2024: Update billing system to remove prior authorization requirements for CPT 11971 when used with breast cancer diagnosis codes C50.011-C50.929, C79.81, D05.00-D05.92, Z42.1, Z85.3. Remove ordering physician requirement for all PT/OT services. Update genetic testing authorization rules for codes 81162-81167, 81206-81208, 81210, 81212, 81215-81217, 81261-81264, 81340-81342, 81265-81268, and 81270. Mark codes 81240 and 81241 as not covered for Medicare Advantage and not medically necessary for Commercial plans.