Medical Policy Update
Blue Cross and Blue Shield of Nebraska (BCBSNE) is proud to work with our provider network to serve your patients, our members. We are updating several medical policies. Please review the changes and effective dates outlined here:
MPC November 2026
New Medical Policies
Medical Policy: III.277 Evolent Joint Surgery (Hip, Knee, Shoulder Surgeries) This is for all employer groups
Effective Date: 11/01/2026
Preauthorization Required: Yes
Policy
Evolent will perform the preauthorizations
Submission of the pre-service review.
- Call toll free 1-866-972-9642 from 7:00am - 7:00pm (CST) (8:00am-8:00pm EST).
- Visit the website www.RadMD.com
| Revision Knee Arthroplasty | 27486, 27487 |
| Partial-Unicompartmental Knee Arthroplasty (UKA) | 27446, 27438 |
| Knee Manipulation under Anesthesia (MUA) | 27570, 29884 |
| Knee Ligament Reconstruction/Repair | 27405, 27407, 27409, 27427, 27428, 27429, 29888, 29889 |
| Knee Meniscectomy/Meniscal Repair/Meniscal Transplant | 27332, 27333, 27403, 29868, 29880, 29881, 29882, 29883 |
| Knee Surgery – Other | 27412, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 29866, 29867, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29885, 29886, 29887, G0289 |
| Revision Shoulder Arthroplasty | 23473, 23474 |
| Total/Reverse Shoulder Arthroplasty or Resurfacing | 23472 |
| Partial Shoulder Arthroplasty/Hemiarthroplasty | 23470 |
| Frozen Shoulder Repair/Adhesive Capsulitis | 29825 |
| Shoulder Labral Repair | 23450, 23455, 23460, 23462, 23465, 23466, 29806, 29807 |
| Shoulder Rotator Cuff Repair | 23410, 23412, 23420, 29827 |
| Shoulder Surgery - Other | 23120, 23125, 23130, 23405, 23415, 23430, 23700, 29805, 29819, 29820, 29821, 29822, 29823, 29824, 29825, +29826, 29828 |
Revised Medical Policy
Medical Policy: I.200 Amniotic Membrane and Amniotic Fluid and I.202 Bioengineered Skin and Soft Tissue Substitutes
Effective Date: 11/01/2026
Preauthorization Required: Yes
Adding Codes: 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278