Medical Policy Updates
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:
Effective November 1, 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/Conversion Hip Arthroplasty | 27132, 27134, 27137, 27138 |
| Total Hip Arthroplasty/Resurfacing | 27130, S2118 |
| Femoroacetabular Impingement (FAI) Hip Surgery | 29914, 29915, 29916 |
| Hip Surgery - Other | 29860, 29861, 29862, 29863 |
| Revision Knee Arthroplasty | 27486, 27487 |
| Total Knee Arthroplasty (TKA) | 27447 |
| 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 |
Medical Policy: I.221 Psychological and Neuropsychological Testing
Effective Date: 11/01/2026
Preauthorization Required: Yes
Codes: 96116, 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139
Prior Authorization will be needed after the 5th hour of testing.
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