Medical Policy and Coding Updates

Effective June 5, 2026

Carpal Tunnel Release Surgical Treatments, 7.01.595  Individual | Group
Medical necessity criteria updated

• Carpal tunnel release surgical treatments are subject to review per Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525.

Intracoronary Drug Delivery Balloon Procedures, 7.01.97  Individual | Group
New policy

• The use of percutaneous coronary intervention with a drug-coated balloon for the treatment of intracoronary in-stent restenosis is considered investigational.

Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525  Individual | Group
Medical necessity criteria added

• Carpal Tunnel Release Surgical Techniques, 7.01.595 added to list of surgical or diagnostic procedures that require review for Site of Service ASC for Select Surgical or Diagnostic Procedures in Adults, 11.01.525.

Effective for dates of service on and after June 5, 2026, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Radiation Therapy. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

Radiation Therapy Program Expansion

Addition of Electronic Brachytherapy – Skin and Orthovoltage

• Clinical indications
  • Treatment of non‑melanoma skin cancers, including basal cell carcinoma and squamous cell carcinoma
  • Use in select non‑malignant conditions

Non-malignant disease review

• Carelon will implement specific appropriate use criteria for Radiation Therapy in Non‑Malignant Diseases including:
  • Keloid prevention
  • Dupuytren’s contracture
  • Ledderhose contracture
  • Peyronie’s disease
  • Plantar fasciitis
• Radiation therapy recognized as a low‑dose treatment option for certain benign proliferative and inflammatory conditions
• Non‑malignant indications reviewed under Carelon’s Non‑Malignant Disease clinical guidelines

For questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines.

Effective May 1, 2026

Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525  Individual | Group
Title change

• Changed from Site of Service Ambulatory Service Center Select Surgical Procedures to Site of Service Ambulatory Service Center Select Surgical or Diagnostic Procedures in Adults.

Medical necessity criteria added

• Upper Gastrointestinal (UGI) Endoscopy for Adults, 2.01.533 added to list of surgical or diagnostic procedures that require review for Site of Service ASC for Select Surgical or Diagnostic Procedures.

Upper Gastrointestinal (UGI) Endoscopy in Adults, 2.01.533  Individual | Group
Title change

• Changed title from Upper Gastrointestinal (UGI) Endoscopy for Adults to Upper Gastrointestinal (UGI) Endoscopy in Adults.

Medical necessity criteria added

• Site of Service Ambulatory Service Center (ASC) Select Surgical Procedures in Adults, 11.01.525 criteria added.

Effective April 8, 2026

Mobile Cardiac Telemetry and Implantable Loop Recorders, 2.02.510  Individual | Group
Title changed

• Policy title expanded from Mobile Cardiac Outpatient Telemetry to Mobile Cardiac Telemetry and Implantable Loop Recorders

Medical necessity criteria added

• Implantable loop recorders may be considered medically necessary when criteria are met
• Implantable loop recorders are subject to review per Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525

Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525  Individual | Group
Medical necessity criteria added

• Mobile Cardiac Telemetry and Implantable Loop Recorders, 2.02.510 added as an included policy to indicated that implantable loop recorders only require review for Site of Service ASC for Select Surgical or Diagnostic Procedures in Adults

Effective March 4, 2026

Electrophysiology (EP) studies, 2.02.517  Individual | Group
New policy

• Electrophysiology studies may be considered medically necessary when criteria are met

Endovascular Stent Grafts for Abdominal Aortic Aneurysms, 7.01.601  Individual | Group
New policy

• The use of endoprostheses approved by the Food and Drug Administration (FDA) as a treatment of abdominal aortic aneurysms may be considered medically necessary when criteria are met

Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570  Individual | Group
Medical necessity criteria updated

• Amondys 45 (casimersen), Duvyzat (givinostat), Exondys 51 (eteplirsen), Viltepso (vitolarsen), and Vyondys 53 (golodirsen) re-authorization criteria updated to require that documentation is provided that the individual is ambulatory without needing an assistive device (e.g., cane, walker, wheelchair)

Shoulder Arthrotomy in Adults, 7.01.605  Individual | Group
New policy

• Shoulder arthrotomy in adults may be considered medically necessary when criteria are met

Revised medical policies
Effective March 1, 2026

Carpal Tunnel Release Surgical Treatments, 7.01.595  Individual | Group
Medical necessity criteria updated

• Carpal tunnel release surgery criteria simplified and changed to the following:
  • A clinical diagnosis of carpal tunnel syndrome must be documented by either electrodiagnostic testing (e.g., nerve conduction study or electromyography), or
  • A CTS‑6 (Carpal Tunnel Symptom Scale) score greater than 12.
• Ultrasound-guided percutaneous intracarpal tunnel balloon dilation release was added to the list of surgical techniques considered investigational.

Deep Brain Stimulation, 7.01.63  Individual | Group
Medical necessity criteria updated

• Deep brain stimulation (DBS) for treatment-resistant obsessive-compulsive disorder (OCD) changed from investigational to medically necessary when criteria are met.
• Contraindications for DBS for OCD added.
• Use of DBS in conjunction with transcranial magnetic stimulation (TMS) or any other neuromodulation modality is considered not medically necessary.
• Documentation requirements added specifically for DBS for OCD.

Electrical Stimulation Devices, 1.01.507  Individual | Group
Medical necessity criteria added

• Transcutaneous magnetic stimulation of peripheral nerves for the management of chronic intractable pain is considered investigational.

Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.554  Individual | Group
Investigational criteria added

• Hypoglossal nerve stimulators with other food and drug administration (FDA) approved devices (e.g., Genio) for the treatment of clinically significant obstructive sleep apnea syndrome are considered investigational.

Revised pharmacy policies
Effective March 1, 2026

ALK Tyrosine Kinase Inhibitors, 5.01.538  Individual | Group
Medical necessity added

• Alecensa (alectinib) and Lorbrena (lorlatinib) for the treatment of metastatic or recurrent inflammatory myofibroblastic tumor (iMT) with ALK translocation when the individual has had treatment failure on prior Xalkori (crizotinib) therapy.

Medical necessity criteria updated

• Lorbrena (lorlatinib) criteria updated to add a prescribed quantity limit per 30 days.
• Alunbrig (brigatinib) and Zykadia (ceritinib) criteria updated for the treatment of iMT to require that it is for metastatic or recurrent disease and the individual has had treatment failure on prior Xalkori (crizotinib) therapy.

Denosumab Products, 5.01.658  Individual | Group
Medical necessity criteria added

• Boncresa (denosumab-mobz), Jubereq (denosumab-desu), Osvyrti (denosumab-desu), Oziltus (denosumab-mobz).

Drugs for Rare Diseases, 5.01.576  Individual | Group
Medical necessity criteria added

• Daybue Stix (trofinetide) for the treatment of Rett syndrome may be considered medically necessary when criteria are met.
• Zycubo (copper histidinate) for the treatment of Menkes disease may be considered medically necessary when criteria are met.
• Forzinity (elamipretide) to improve muscle strength in individuals with Barth syndrome may be considered medically necessary when criteria are met.

Medical necessity criteria updated

• Cablivi (caplacizumab-yhdp) criteria updated decreasing age requirement from 18 years or older to 12 years or older.
• Givlaari (galoisian) re-authorization criteria to clarify documentation requirements.
• Oxlumo (lumasiran) criteria updated to clarify lab requirements for diagnosis confirmation and remove the exclusion of kidney transplant.
• Livmarli (maralixibat) criteria updated to exclude individuals with a subgroup of progressive familial intrahepatic cholestasis type 2 and to clarify its quantity limits.
• Daybue (trofinetide) criteria updated to increase approval duration from 3 to 6 months.
• Cholbam (cholic acid) criteria updated to remove dose limit.

Excessively High Cost Drug Products with Lower Cost Alternatives, 5.01.560  Individual | Group
Medical necessity criteria added

• Generic droxidopa for the treatment of symptomatic neurogenic orthostatic hypotension when criteria are met.

Medical necessity criteria removed

• Adazin, Lidocaine 3.88%, Pain Relief, Regenecare, Scar, and Synvexia TC criteria removed.
• Synera patches and Sitavig criteria removed as they have been withdrawn from the market.

Medical necessity criteria updated

• Northera (droxidopa) criteria updated to require trial of generic droxidopa.
• Zileuton extended-release and Zyflo criteria updated to add a quantity limit of 120 tablets per 30 days.

Growth Hormone Therapy, 5.01.500  Individual | Group
Medical necessity criteria updated

• Serostim (somatropin) criteria updated to include a quantity limit of 28 vials per 28 days.

Immune Checkpoint Inhibitors, 5.01.591  Individual | Group
Medical necessity criteria updated

• Keytruda (pembrolizumab) and Keytruda Qlex (pembrolizumab and berahyaluronidase alfa-pmph) criteria updated to add new indication for the treatment of muscle invasive bladder cancer (MIBC) when criteria are met.
• Keytruda Qlex criteria updated to include indication for treatment of resectable locally advanced Head and Neck Squamous Cell Cancer when criteria are met.
• Opdivo Qvantig (nivolumab and hyaluronidase-nvhy) criteria updated to include treatment of unresectable or metastatic hepatocellular carcinoma, as a first-line treatment following combination treatment with intravenous Opdivo (nivolumab) and Yervoy (ipilimumab).
• Imfinzi (durvalumab) criteria updated to add new indication for the treatment of resectable gastric or gastroesophageal junction adenocarcinoma and used in combination with fluorouracil, leucovorin, oxaliplatin, and docetaxel chemotherapy as neoadjuvant and adjuvant treatment, followed by single agent durvalumab.
• Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) criteria updated for the treatment of unresectable or metastatic alveolar soft part sarcoma changing requirement from adult to pediatric individuals aged 12 years and older who weigh at least 40 kg.

Intravitreal Corticosteroids, 5.01.619  Individual | Group
Medical necessity criteria updated

• Ozurdex (dexamethasone intravitreal implant) criteria updated to remove diagnosis of branch retinal vein occlusion or central retinal vein occlusion confirmed by fluorescein angiogram.

Medical Necessity Criteria for Pharmacy Edits, 5.01.605  Individual | Group
Medical necessity criteria added

• Yartemlea (narsoplimab-wuug) for the treatment of hematopoietic stem cell transplant-associated thrombotic microangiopathy may be considered medically necessary when criteria are met.

Medical necessity criteria updated

• Accrufer (ferric maltol) criteria updated decreasing age requirement from 18 years of age or older to 10 years of age or older.

Miscellaneous Oncology Drugs, 5.01.540  Individual | Group
Medical necessity criteria updated

• Rubraca (rucaparib) criteria updated to remove requirement for prior therapy with a taxane-based chemotherapy for treatment of metastatic castration-resistant prostate cancer.
• Rozlytrek (entrectinib) for the treatment of solid tumors criteria updated to decrease age requirement from 12 years to 1 month and older.
• Lumakras (sotorasib) and Ojjaara (momelotinib) criteria updated to add a quantity limit per 30 days.
• Matulane (procarbazine hydrochloride) criteria updated to remove the requirement for trial of generic procarbazine hydrochloride.
• Pemazyre (pemigatinib) criteria updated to add a quantity limit per 28 days.
• Darzalex (daratumumab), Hepzato Kit, Ibrance (palbociclib), Romvimza (vimseltinib), Tecelra (afamitresgene autoleucel), and Vyloy (zolbetuximab-clzb) criteria updated to remove Eastern Cooperative Oncology Group (ECOG) requirement.
• Kyprolis (carfilzomib) criteria updated to include isatuximab and dexamethasone in list of treatments for relapsed or refractory multiple myeloma.
• Generic temozolomide oral and Temodar (temozolomide) IV criteria for treatment of glioblastoma to remove requirement that individual is newly diagnosed.
• Romvimza (vimseltinib) criteria updated to include a quantity limit to 2 capsules weekly.
• Darzalex Faspro criteria updated to remove ECOG requirement, and adding new indication in combination with bortezomib, lenalidomide, and dexamethasone in newly diagnosed individuals who are ineligible for autologous stem cell transplant.

Medical necessity criteria added

• Komzifti (ziftomenib) for the treatment of relapsed or refractory acute myeloid leukemia with a susceptible nucleophosmin 1 mutation when criteria are met.

Medical necessity criteria removed

• Temodar (temozolomide) oral criteria removed as product has been discontinued.

Omisirge (omidubicel), 5.01.638  Individual | Group
Medical necessity criteria added

• Omisirge (omidubicel-onlv) for the treatment of severe aplastic anemia in adult and pediatric individuals aged 6 years and older when criteria are met.

Pharmacologic Treatment of Hemophilia, 5.01.581  Individual | Group
Medical necessity criteria updated

• Hympavzi (marstacimab-hncq) criteria updated to clarify the indication is for hemophilia A without factor VIII inhibitors or hemophilia B without factor IX inhibitors.
• Hympavzi criteria updated to include the 300 mg weekly maintenance dose limit.
• Qfitlia (fitusiran) criteria updated to clarify the indication is for hemophilia A (congenital factor VIII deficiency) or hemophilia B (congenital factor IX deficiency) with or without factor VIII or IX inhibitors.

Pharmacologic Treatment of Psoriasis, 5.01.629  Individual | Group
Medical necessity criteria updated

• Tremfya (guselkumab) criteria updated to include individuals weighing at least 40 kg.

Medical necessity criteria added

• Otezla XR (apremilast extended release) for the treatment of psoriasis in individuals aged 6 years and older and weigh at least 50 kg.
• Otezla XR added to list of preferred alternatives for Bimzelx (bimekizumab-bkzx), Siliq (brodalumab), Cosentyx (secukinumab), Cimzia (certolizumab-pegol), and Ilumya (tildrakizumab-asmn).

Pharmacologic Treatment of Psoriatic Arthritis, 5.01.645  Individual | Group
Medical necessity criteria removed

• Enbrel and Simponi Aria criteria separated from Adalimumab products removing note.

Medical necessity criteria added

• Otezla XR (apremilast extended-release) for the treatment of psoriatic arthritis when criteria are met.

Medical necessity criteria updated

• Simponi Aria (golimumab) criteria updated decreasing age requirement from 18 years or older to 2 years or older.
• Tremfya (guselkumab) criteria updated to include individuals weigh at least 40 kg.
• Otezla (apremilast) criteria updated to specify that individual weighs at least 20 kg.
• Otezla XR added to list of preferred alternatives for Cimzia, Simponi, Bimzelx, Cosentyx, and Orencia.

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  Individual | Group
Medical necessity criteria updated

• Benlysta (belimumab) SC criteria for the treatment of active lupus nephritis updated to decrease age requirement from 18 years to 5 years and older.

Medical necessity criteria added

• Otezla XR (apremilast extended-release) for the treatment of Behcet's disease.

Spravato (esketamine) Nasal Spray, 5.01.609  Individual | Group
Medical necessity criteria updated

• To confirm that depression is not bipolar depression, a new criterion was added for new treatment episodes and reauthorization requiring no current or prior diagnosis of bipolar disorder and no history of manic or hypomanic episodes.
• To confirm that depression is not psychotic depression, a criterion requiring no current psychosis was added for reauthorization.

No updates this month.

Effective June 5, 2026

Electronic Brachytherapy for Nonmelanoma Skin Cancer, 8.01.62
Policy deleted

• Policy deleted. Services will be reviewed by Carelon Medical Benefits Management.

Added codes
Effective June 5, 2026

Carelon Medical Benefits Management Radiation Oncology
Now reviewed by Carelon for medical necessity and prior authorization.

70472

Intracoronary Drug Delivery Balloon Procedures, 7.01.97  Individual | Group
Now considered investigational.

0913T, 0914T, C9610

Effective May 1, 2026

Site of Service Ambulatory Service Center (ASC): Select Surgical Procedures for Adults, 11.01.525  Individual | Group
Now requires review for medical necessity, in addition to current review for site of service and prior authorization.

43235, 43238, 43239, 43242

Effective April 8, 2026

Mobile Cardiac Outpatient Telemetry and Implantable Loop Recorders, 2.01.510  Individual | Group
Now requires review for medical necessity and prior authorization, in addition to review for site of service.

33285, E0616

Now requires review for medical necessity.

C1764

Site of Service Ambuatory Service Center (ASC): Select Surgical Procedures in Adults, 11.01.525  Individual | Group
Now requires review for medical necessity and prior authorization, in addition to review for site of service.

33285, E0616

Effective March 4, 2026

Electrophysiology (EP) Studies, 2.02.517  Individual | Group
Now requires review for medical necessity and prior authorization.

93609, 93613, 93619, 93620, 93621, 93622, 93624, 93653, 93654

Endovascular Stent Grafts for Abdominal Aortic Aneurysms, 7.01.601  Individual | Group
Now requires review for medical necessity and prior authorization.

34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708, 34710, 34711, 34717, 34718, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848

Non-covered Services and Procedures, 10.01.517  Individual | Group
Now non-covered.

0751T, 0752T, 0754T, 0755T, 0757T, 0758T, 0759T, 0760T, 0761T, 0762T, 0763T

Shoulder Arthrotomy in Adults, 7.01.605  Individual | Group
Now requires review for medical necessity and prior authorization.

20670, 20680, 23040, 23044, 23101, 23105, 23106, 23107, 23120, 23130, 23410, 23412, 23415, 23420, 23450, 23455 , 23460, 23462 , 23465, 23466, 23550, 23552, 23585, 23615, 23616, 23630, 23660, 23670, 23680

Effective March 1, 2026

Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.554  Individual | Group
Now considered investigational.

0978T, 0979T, 0980T

Drugs for Rare Diseases, 5.01.576  Individual | Group
Now requires review for medical necessity and prior authorization.

J1809

Revised codes
Effective June 5, 2026

Carelon Medical Benefits Management Radiation Oncology
Now reviewed by Carelon for medical necessity and prior authorization.

77436, 77437, 77438, 77439

Carpal Tunnel Release Surgical Techniques, 7.01.595  Individual | Group
Site of Service Ambulatory Service Center (ASC) Select Surgical or Diagnostic Procedures in Adults, 11.01.525  Individual | Group
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

29848, 64721

Effective May 1, 2026

Upper Gastrointestinal (UGI) Endoscopy for Adults, 2.01.533  Individual | Group
Now requires review for medical necessity, in addition to current review for site of service and prior authorization.

43235, 43238, 43239, 43242

Effective March 1, 2026

Negative Pressure Wound Therapy Devices, 1.01.508  Individual | Group
Now considered investigational.

A9272, 97607, 97608

Non-Covered Experimental/Investigational Services, 10.01.533  Individual | Group
Now considered investigational.

C1607

Removed codes
Effective June 5, 2026

Electronic Brachytherapy for Nonmelanoma Skin Cancer, 8.01.62  Individual | Group
Now reviewed by Carelon for medical necessity and prior authorization.

77436, 77437, 77438, 77439

Effective March 1, 2026

Negative Pressure Wound Therapy Devices, 1.01.508  Individual | Group
No longer requires review.

A7000, A7001

No updates this month.

No updates this month.

No updates this month.

No updates this month.

No updates this month.

Effective March 4, 2026

Laryngeal Injection for Vocal Cord Augmentation, 2.01.541  Individual
Title changed

• Title changed from Laryngeal Injection for Vocal Cord Augmentation Augmentation to Office-based Laryngeal Procedures

Medical necessity criteria updated

• Additional procedures and diagnoses added; policy scope aligned with procedures performed in the office setting

Services Reviewed Using InterQual Criteria, 10.01.530  Individual
Medical necessity criteria updated

• Removed reference to endovascular stent grafts for abdominal aortic aneurysms.
• Services will now be reviewed using Endovascular Stent Grafts for Abdominal Aortic Aneurysms, 7.01.601

No updates this month.

No updates this month.

No updates this month.

Removed codes
Effective March 4, 2026

Services Reviewed Using InterQual Criteria, 10.01.530  Individual
No longer reviewed using InterQual criteria.

34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708, 34710, 34712, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848