Medicare Advantage Medical Policy Updates
Effective July 15, 2026
Blue Cross and Blue Shield of Nebraska Medicare Advantage 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:
New Medical Policies
Medical Policy: MA Mohs Micrographic Surgery
Effective Date: 07/15/2026
Preauthorization Required: Yes
Codes: 17311 17312 17313 17314 17315
Policy Statement:
LCD L35494 Mohs Micrographic Surgery
Medical Policy: MA Prostatectomy
Effective Date: 07/15/2026
Preauthorization Required: Yes
Codes: 55810 55812 55815 55840 55842 55845 55866
Will utilize MCG criteria.
Revised Medical Policies
Medical Policy: M.12 Interventional Pain Management and Cervical and Lumbar Spine Surgery
Effective Date: 07/15/2026
Preauthorization Required: Yes
Adding Codes to Current Policy: 22586 22802 22804 63170 63191 63200 C1821
Will utilize MCG criteria.
Medical Policy: M.15 Procedures Following NCD, LCD or MCG
Effective Date: 07/15/2026
Preauthorization Required: Yes
43445: NCD 230.10 Incontinence Control Devices
37215 37216: NCD 20.7 Percutaneous Transluminal Angioplasty (PTA)
E0304: LCD L33820 Hospital Beds and Accessories
E0472 E0561 E0562 E0601: NCD 240.4 Continuous Positive Airway Pressure (CPAP) Therapy for OSA
E0615 NCD 20.8.2 Self Contained Pacemaker Monitors
E0749: NCD 150.2 Osteogenic Stimulators
E1035, E1036: LCD L33799 Patient Lifts
K0738: LCD L33797 Oxygen and Oxygen Equipment
Unlisted Codes:
17999 20999 21299 28899 41599 58575 79999: will utilize MCG
22899: NCD 150.11 Thermal Intradiscal Procedures and MCG for Musculoskeletal Surgeries
42299: LCD L34526 Surgical Treatment for Obstructive Sleep Apnea
55899: NCD 160.26 Cavernous Nerves by Electrical Stimulation with Penile Plethysmography and MCG for Urologic Surgeries
64999: NCD 150.11 Thermal Intradiscal Procedures, 20.18 Carotid Body Resection/Carotid Body Denervation and MCG Neurosurgery and Vagus Nerve Blocking Device
69949: NCD 50.5 Oxygen Treatment of Inner Ear/Carbon Therapy and 50.7 Cochleostomy with Neurovascular Transplant for Meniere’s Disease
77799: M.20 Accelerated Irradiation Therapy, Brachytherapy
78999: Medicare, CMS Manual System, Pub 100-04
Medical Policy: M.30 Permanent Cardiac Pacemakers
Effective Date: 07/15/2026
Preauthorization Required: Yes
Adding Codes to Current Policy: 33210 33211 33212 33213 33214 33274 C1779 C1785 C1786 C1898 C2619 C2620
Medical Policy: M.16 Part B Utilization Management in the Absence of NCD or LCD/ Medicare Chapter 15
Effective Date: 07/15/2026
Preauthorization Required: Yes
Codes:
The following unlisted codes will require a PA: C9399 J3490 J3590 J7199 J7599 J7799 J7999 J9999
Medical Policy: M.48 Intranasal Cryoablation or Radiofrequency Ablation for Rhinitis
Effective Date: 7/15/2026
Preauthorization Required: Yes
Adding Code to the Prior Authorization: 30117