Medicare Advantage

Starting in March 2026, new medical policies will go into effect for both Commercial and Medicare Advantage plans. In Feb. 2026, revisions to existing medical policies will also take effect. To ensure a smooth transition and minimize any disruption to your current processes, please review the updated policies below.

MA New Polices Effective 3/1/26

Amniotic Membrane and Amniotic Fluid
Policy number: M.14
Summary: Amniotic membrane is covered for specific eye and wound conditions (e.g., diabetic ulcers, corneal ulcers), but amniotic fluid injections are not medically necessary for any indication. Only specific products will be allowed; all others will be considered non-covered on CMS (01/01/2026).

Benign Prostate Hyperplasia
Policy Number: M.29
Summary: Covers specific minimally invasive treatments for BPH—such as prostatic urethral lift (Urolift), water vapor therapy (Rezum), and transurethral waterjet ablation—when strict clinical criteria are met, while deeming other procedures (e.g., PAE, cryoablation, HIFU) not medically necessary.

Single Chamber and Dual Chamber Permanent Cardiac Pacemaker and Defibrillators
Policy Number: M.30
Summary: Covers permanent pacemakers for symptomatic bradycardia and implantable cardioverter defibrillators (ICDs) for specific high-risk cardiac conditions per CMS NCD criteria, while excluding reversible causes and non-indicated uses.

Electrophysiology Testing and Cardiac Ablation
Policy Number: M.31
Summary: Coverage for electrophysiology (EP) testing and cardiac ablation is based on InterQual criteria to determine medical necessity for diagnostic and therapeutic procedures.

Non-Coronary Vascular Stents
Policy Number: M.32
Summary: Coverage for non-coronary vascular stent procedures is based on CMS LCD criteria (L35998 and A57590) to determine medical necessity for vascular interventions.

Cardiac Catheterization
Policy Number: M.33
Summary: Covers right, left, or combined heart catheterization when clinically indicated for diagnosis or treatment planning of cardiac conditions, while excluding non-indicated uses such as routine angioplasty or electrophysiologic studies.

Orthognathic Surgery
Policy Number: M.34
Summary: Covers orthognathic surgery for correction of skeletal deformities causing functional impairment when strict clinical criteria are met, and for obstructive sleep apnea after failure of CPAP; excludes cosmetic indications and procedures lacking proven effectiveness.

Urinary Incontinence Treatment
Policy Number: M.35
Summary: Allows periurethral bulking agent injections for stress urinary incontinence meeting specific criteria, while deeming adjustable balloon continence devices and other non-proven treatments not medically necessary.

Non-invasive Cerebrovascular and Peripheral Arterial Vascular Studies
Policy Number: M.36
Summary: Coverage for non-invasive cerebrovascular and peripheral arterial vascular studies follows CMS LCD criteria (L35753, A57592, L35761, A57593) to determine medical necessity for diagnostic imaging.

Echocardiogram, Transthoracic (TTE) and Transesophageal (TEE)
Policy Number: M.37
Summary: Echocardiogram coverage is based on InterQual criteria, with PA required for TEE but not for TTE, ensuring appropriate use for cardiac evaluation.

Percutaneous Coronary Intervention (PCI)
Policy Number: M.38
Summary: PCI procedures are covered when meeting CMS LCD L34761 criteria for medical necessity in coronary artery disease treatment.

Category III Codes
Policy Number: M.39
Summary: Category III procedures are generally considered experimental or not medically necessary unless proven safe, effective, and consistent with accepted medical standards.

Physical Medicine and Rehabilitation
Policy Number: M.40
Summary: Continued physical therapy beyond 12 visits requires prior authorization and documentation showing functional improvement, medical necessity, and inability to perform therapy independently.

Prostate Rectal Spacers
Policy Number: M.41
Summary: Covers prostate rectal spacers (e.g., SpaceOAR) for patients with localized prostate cancer undergoing hypofractionated radiation therapy when strict clinical criteria are met; not medically necessary if criteria are not met.

MA Revised Policies effective 3/1/26

Bioengineered Skin and Soft Tissue Substitutes
Policy Number: M.3
Summary: Covers bioengineered skin substitutes for diabetic foot ulcers, venous leg ulcers, and certain reconstructive or burn indications when strict LCD criteria and approved product lists are met; all other uses and products are considered non-covered. Only specific products will be allowed; all others will be considered non-covered on CMS (01/01/2026).

MA Cosmetic and Reconstructive Surgery (Codes Added)
Policy Number: M.5
Summary: Adds new codes for cosmetic and reconstructive procedures; coverage follows NCD 250.5, NCD 140.2, and LCD 39051 criteria for medical necessity.

MA Cosmetic and Reconstructive Surgery (Tissue Transfer Flaps)
Policy Number: M.5
Summary: Adds tissue transfer flap codes; coverage determined using InterQual criteria for reconstructive surgery indications.

MA Radiology
Policy Number: M.13
Summary: Radiology procedures require PA and follow InterQual, NCD, and LCD criteria for specific codes, including nuclear medicine and advanced imaging.

MA Procedures Following NCD, LCD or InterQual
Policy Number: M.15
Summary: Adds genetic testing, behavioral therapy, and device codes; coverage based on NCD and LCD guidelines for medical necessity.

Evolent Joint Surgeries
Policy Number: (No M-number provided)
Summary: Joint surgery codes require prior authorization, managed by Evolent, for hip, knee, and shoulder procedures.

Commercial New Policies effective 3/9/26

Non‑Urgent Air Ambulance Transport
Policy Number: I.217
Summary: Requires preauthorization for planned air ambulance transfers and is covered only when the patient needs acute inpatient care unavailable at the originating facility, the nearest capable receiving facility is used, and no safer lower‑intensity transport option (ground or commercial air) is appropriate; transports for convenience are not medically necessary.

Commercial Revised Policies effective 2/15/26

Computed Tomography Angiography (CTA)
Policy Number: IV.62
Summary: The use of noninvasive fractional flow reserve following a positive coronary computed tomography angiography (75580) may be considered medically necessary to guide decisions about the use of invasive coronary angiography in individuals with stable chest pain at intermediate risk of coronary artery disease (i.e., suspected or presumed stable ischemic disease). All other uses are considered investigational.

Bone Mineral Density Measurement
Policy Number: IV.78
Summary: Screening for osteoporosis using Quantitative Computed Tomography (QCT) (77078), Ultrasound Densitometry and/or Vertebral Fracture Densitometry (77085, 77086, 76777) are Investigational.

Amniotic Membrane and Amniotic Fluid
Policy Number: I.200
Summary: The use of amniotic membrane using the following products **(Affinity^®, AmnioBand^® Membrane, Biovance^®, EpiCord^®, EpiFix^®, Grafix™, NuShield^®) is considered scientifically validated for treating specific conditions. These include diabetic lower extremity ulcers, neurotrophic keratitis, corneal ulcers or melts, pterygium repair, Stevens-Johnson syndrome of the eye, persistent epithelial defects, and chronic venous ulcers that have not healed after more than four weeks of standard therapy.

Bioengineered Skin and Soft Tissue Substitutes
Policy Number: I.202
Summary: The use of bioengineered skin and soft tissue substitutes is considered scientifically validated for the following indications:
Breast reconstruction (including each of the following: AlloDerm^®, Cortiva^® [AlloMax™], DermACELL™, DermaMatrix™, FlexHD^®, FlexHD^® Pliable™) OR
Diabetic lower extremity ulcers (AlloPatch^®a, Apligraf^®, Dermagraft^®, Integra^® Omnigraft™ Dermal Regeneration Matrix (also known as Omnigraft™), and Integra Flowable Wound Matrix, mVASC^®, TheraSkin^®) OR
Venous insufficiency lower extremity ulcers (Apligraf^®, Oasis™ Wound Matrix) OR
Dystrophic epidermolysis bullosa (OrCel™ (for the treatment of mitten-hand deformity when standard wound therapy has failed and when provided in accordance with the humanitarian device exemption [HDE] specifications of the U.S. Food and Drug Administration [FDA]) OR
Second- or third-degree burns (Epicel^® (for the treatment of deep dermal or full-thickness burns comprising a total body surface area ≥30% when provided in accordance with the HDE specifications of the FDA), Integra^® Dermal Regeneration Template.

Oscillatory Devices for Respiratory Disorders
Policy Number: VII.35
Summary: High-frequency chest wall oscillation and oscillatory PEP devices are covered for cystic fibrosis, primary ciliary dyskinesia, and bronchiectasis; all other uses, including Volara device, are investigational.

Surgeries for Obstructive Sleep Apnea
Policy Number: III.62
Summary: Covers unilateral hypoglossal nerve stimulation (e.g., Inspire^®) for adults and adolescents with Down syndrome under strict clinical criteria; bilateral hypoglossal nerve stimulation (e.g., Genio Device) is considered investigational.
 

Notifications about medical policy updates can be found under the “Recent Updates” section on the Alerts and Updates page.

Effective March 1, 2026 

BCBSNE will be discontinuing the auto-approval process for Skilled Nursing Facility (SNF) admissions for Medicare Advantage (MA) Participating (PAR) providers. This change follows prior updates communicated in December 2024 and August 2025 regarding the auto-approval policy. 

What’s Changing

• Auto-approval for SNF admissions will no longer be available beginning March 1, 2026. 
• All SNF admissions will require prior authorization for the initial stay and any subsequent days. 

What Providers Need to Do 

• Submit prior authorization requests for all SNF admissions starting March 1, 2026. 
  • Preferred method: PAR providers should submit via NaviNet
  • Non-PAR / Out-of-State providers: Refer to the Preauthorization page on NaviNet for instructions. 
• Continue to provide required clinical documentation to support medical necessity. 
• Ensure timely submission to avoid delays in member care. 
• Note: Medicare Advantage fax lines are available however it is encouraged to submit electronically when possible. 

Important Reminders 

• The current auto-approval process (three-day auto-approval for PAR SNFs) remains in effect until Feb. 28, 2026. 
• Swing bed stays remain ineligible for auto-approval and require prior authorization. 

Thank you for your attention and collaboration as we implement this updated process.

Effective Jan. 1, 2026, Blue Cross and Blue Shield of Nebraska will align its Medicare Advantage billing and reimbursement policy for discontinued procedures with the commercial policy.

When a physician or other qualified health care professional elects to terminate a surgical or diagnostic procedure due to extenuating circumstances, append modifier 53 to the procedure code. This modifier indicates the procedure was started but not completed.

Reimbursement Details:

• Professional discontinued procedures will be reimbursed at 50% of the allowable unmodified amount.
• Multiple procedure reductions still apply when applicable.

Please ensure your billing teams are aware of this update and adjust claims accordingly.

Effective Nov. 1, 2025, BCBSNE Medicare Advantage is implementing updated billing guidance for the use of HCPCS modifiers GA, GX, GY, and GZ. These modifiers support accurate claims processing and help determine appropriate member or provider liability.

This new policy will be effective Nov. 1, 2025, and will be available for review prior to the effective date.

Please refer to Section 10.2, Chapter 4 of the Medicare Managed Care Manual for additional context on billing and payment rules that may differ from Original Medicare.

Modifier Usage and Outcomes

• GA – Pre-Service Notice of Non-Coverage Provided
  • Use when an ABN is on file for services expected to be denied due to lack of medical necessity.
  • May be appended to specific or miscellaneous HCPCS codes.
  • Outcome: Claim is member liability. You may bill the member.
  • Note: If a non-covered service is billed without a GA modifier, the claim will be denied and assigned to provider liability.
• GZ – No Notice of Non-Coverage Provided
  • Use when services are expected to be denied and no ABN was issued.
  • Outcome: Claim is provider liability. You may not bill the member.
• GX – Not Required
  • Use for statutorily non-covered services submitted with non-covered charges only.
  • May be used in combination with the GY modifier.
  • Outcome: Claim is provider liability.
• GY – Statutorily Excluded Services
  • Use when the item/service is excluded by statute and not a Medicare benefit.
  • Outcome: Claim is member liability. You may bill the member.

Providers are reminded to notify Medicare Advantage members of non-coverage when applicable and to apply the appropriate modifier(s) to ensure compliant billing.