Payment Policy Updates

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May 7, 2026

The following policies received their annual review with no changes:

• Allergen Immunotherapy (95165) Unit Limits
• Modifier 22
• Modifier JW and JZ
• Robotic Surgery

The following policies will be archived effective May 7, 2026:

• Modifier NR and NU
• Modifier RA
• Modifier RR, Modifier KR, and Modifier LL

The following policies received their annual review with the changes noted below:

Abortions-Facility

• Added related chemical abortion codes to the codes and coding guidelines section:
  • S0190 - Mifepristone, oral, 200 mg
    • When billed with International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis codes Z33.2 - encounter for pregnancy test, result positive.
  • S0191 - Misoprostol, oral, 200 mcg
    • When billed with ICD-10-CM diagnosis codes Z32.01 - encounter for elective termination of pregnancy or Z32.01 - encounter for pregnancy test, result positive.

Abortions-Professional

• Added related chemical abortion codes to the codes and coding guidelines section:
  • S0190 - Mifepristone, oral, 200 mg
    • When billed with ICD-10-CM, diagnosis codes Z33.2 - encounter for elective termination of pregnancy or Z32.01 - encounter for pregnancy test, result positive.
  • S0191 - Misoprostol, oral, 200 mcg
    • When billed with ICD-10-CM diagnosis codes Z33.2 - encounter for elective termination of pregnancy or Z32.01 - encounter for pregnancy test, result positive.

Acupuncture

• Added reference statement for dry needling to medical policy: “Please refer to medical policy 2.01.100 - Dry Needling of Trigger Points for Myofascial Pain for medical necessity criteria.”

Contract Exclusions/Disallowed Charges – Inpatient and Outpatient Facility Services

• Added additional examples to contrast section within the radiology category: Indigo Carmine, Indocyanine green, Isosulfan blue, and oral contrast.
• Added additional examples of intravenous (IV) fluid materials under the pharmaceutical category: Flex or Viaflex, Piggyback, Plus, QSB, Diluent, and base.
• Added clarifying statement for observation charges under room and board category.
• Added additional cross reference policies:
  • Critical care in emergency department when patient is discharged to home (facility)
  • Emergency department evaluation and management level of service
  • Preadmission testing
  • Medically unlikely edits (MUEs) / maximum units of service
  • Modifier 90 - reference (outside) laboratory
  • Radiopharmaceuticals and contrast materials

Critical Care in Emergency Department When Patient is Discharged to Home (Facility)

• Annual review. Removed effective date statement: “Effective with claim dates of service on and after October 30, 2024.”

DME List

• New codes added effective October 1, 2025: E0658 and E0659 - capped rental (RR) or outright purchase (NU).
• Deleted code effective October 1, 2025: E0765.

Durable Medical Equipment (DME) / Home Medical Equipment (HME)

• Added criteria from RA policy due to archiving modifier RA policy effective May 7, 2026.
• Added clarifying details for rental modifiers pulled from modifier RR - DME rental, modifier KR - rental item partial month due to archiving the policy effective May 7, 2026.
• Added clarifying details from modifier LL - lease/rental policy: “Submission of DME that is rented daily must include a from and a through date of service along with the appropriate units of service to match the total days rented. If the daily rental period is not continuous, bill a separate line for each unique date of service with a unit of one” due to archiving the policy effective May 7, 2026.
• New codes added to the embedded code list effective October 1, 2025: E0658 and E0659 - capped rental (RR) or outright purchase (NU).
• Deleted the following code from the embedded code list effective October 1, 2025: E0765.

Laboratory and Pathology Billing Guidelines

• In the policy section, revised the subsection on place of service codes (POS) and added examples.
• In the routine venipuncture section, removed: “Only one venipuncture charge will be reimbursed per member, per provider per date of service regardless of the number of tests/draws performed.” Added “Please refer to the medically unlikely edits (MUEs)/maximum units of service policy.”
• Added the “medically unlikely edits (MUEs)/maximum units of service policy” to the cross-reference section.