Quick Overview
- 1 new coding/reimbursement policy: Visit Complexity Add-On Code G2211 (CR-101), which will take effect on 1/1/2026.
- 13 revised medical/coding & reimbursement policies
- No archived polices.
- Coding news & updates
Policy Bulletin
January 2026 Policy Updates
New Policies
Category
Policy Title (Number)
Date
Summary of Change
Visit Complexity Add-On Code G2211
Policy #CR-101
01/01/2026
Created and published this new coding/reimbursement policy.
Revised Policies
*Changes apply ONLY to Commercial plan policy UNLESS summary text appears in bold.
Category
Policy Title (Number)
Date
Summary of Change
Bariatric Surgery Guidelines
Policy #295
12/01/2025
Added exclusion of both the endoscopic sleeve gastroplasty procedure and corresponding CPT code 43889.
Cervical, Lumbar, and Thoracic Spinal Fusion with or without Spinal Decompression
Policy #622
11/21/2025
• Updated requirements pertaining to attempts at conservative therapy in both criterion #4B-ciii and criterion #5C-iii: “Physical therapy or chiropractic therapy: minimum of 12 visits within a 6-week period; must have been performed within the previous year (it is recommended that at least four of these visits be performed in-person), …” • Removed previous criterion #5D (“Willingness to participate in outcomes database”).
Diagnostic and Therapeutic Interventions for Spinal Pain
Policy #626
12/02/2025
• Updated requirements pertaining to attempts at conservative therapy in criterion #A1-c: “Minimum of 12 physical therapy visits or chiropractic visits within a 6-week period; must have been performed within the previous year (it is recommended that at least four of these visits be performed in-person); …” • Modifed requirements in criterion #D1-b and criterion #D2: “… at the same level(s) and at the same side …” • Added new criteria section #C to separate additional coverage parameters that are outlined for Medial Branch Blocks. • Added the following note to criteria section #B for Diagnostic Facet Injections for clarifcation: “Intraarticular facet block will not be reimbursed as a diagnostic test unless MBBs cannot be performed due to specifc documented anatomic restrictions. Successful intraarticular facet block does not qualify for a radiofrequency ablation procedure.”
Genetic Testing: Cardiomyopathy
Policy #665
11/26/2025
For section II, updated coverage criteria to be separated into three new sections (A, B, C): (A - Non-ischemic cardiomyopathy [NICM]); (B - Cardiac amyloidosis); (C - Recurrent acute myocarditis).
Genetic Testing: Minimal Residual Disease (MRD) Assessment
Policy #673
11/28/2025
Added muscle-invasive bladder cancer as a qualifying condition for coverage of ctDNA testing to criterion #6.
Infusion Pumps (External or Implantable)
Policy #609
11/21/2025
• Removed previous criterion #2-b2 (“Nerve blocks) and added new criterion #2-b4: “Pain interventions are either contraindicated or have failed.” • Updated requirements in new criterion #2-b2 pertaining to attempts at conservative therapy: “Physical therapy: minimum of 12 visits within a 6-week period; must have been performed within the previous year (it is recommended that at least four of the visits be performed in-person)… .”
In-Network Coverage of Medical Services with an Out-of-Network Provider
Policy #CR-88
12/11/2025
Removed Washington County from being classified as an urban county for Utah-based plans as the state of Utah now classifies this county as a rural county.
Intracept
Policy #648
11/21/2025
Updated requirements pertaining to attempts at conservative therapy in criterion #1-C: “Physical therapy or chiropractic therapy: minimum of 12 visits within a 6-week period; must have been performed within the previous year (it is recommended that at least four of the visits be performed in-person); …”
Intrathecal Baclofen Therapy
Policy #137
12/15/2025
• Modified requirements in criterion #A-1: “Patient has intractable muscle spasticity.” • Clarified requirements in criterion #B-2: “Patient has a favorable response to a trial using intrathecal dosage of the anti-spasmodic drug prior to pump …”
Peripheral Nerve Treatment
Policy #654
12/08/2025
• Added potential coverage of FDA-approved permanent PNS stimulators and recategorized certain technologies: “Select Health may cover implantation of a permanent FDA-approved PNS stimulator (e.g., StimRouter, Nalu, Curonix Freedom system) after completion of a successful trial and when the above criteria have been met. • Updated requirements pertaining to attempts at conservative therapy in criterion #A-1c, criterion #B-1c, and criterion #C-1c: “Physical therapy: minimum of 12 visits within a 6-week period; must have been performed within the previous year (it is recommended that at least four of these visits be performed in-person).” • Removed previous criterion #B-2 (“Patient has failed a genicular nerve radiofrequency procedure (see MP #557).”
Radiofrequency Ablation (RFA) of the Sacroiliac (SI) Joint
Policy #389
11/21/2025
Updated requirements pertaining to attempts at conservative therapy in criterion #6-b: “Course of physical therapy: minimum of 12 visits within a 6-week period; must have been performed within the previous year (it is recommended that at least four of the visits be performed in-person); …”
Radiofrequency Ablation of the Genicular Nerve
Policy #557
11/21/2025
Updated requirements pertaining to attempts at conservative therapy in criterion #1-C: “Physical therapy: minimum of 12 visits within a 6-week period; must have been performed within the previous year (it is recommended that at least four of these visits be performed in-person); …”
Urine Drug Testing in the Outpatient Setting
Policy #CR-87
12/18/2025
Added the following limitation to this coding/ reimbursement policy: “Select Health will cover up to 50 definitive urine drug monitoring tests within a 12-month period.”
Coding Updates
CPT Codes 93040-93042 for Diagnostic Rhythm ECG Testing
We have observed a notable increase in claims and appeals involving CPT code 93042 billed in conjunction with 93010 or 99285. Based on guidance from National Council on Compensation Insurance (NCCI) and the American Medical Association (AMA), Select Health will deny CPT codes 93042 when billed with 93010 or 99285, as these services are considered included in the primary procedure.
According to NCCI Procedure-to-Procedure (PTP) edits and the NCCI Policy Manual for Medicare Services (Chapter XI, Section I, Subsection 12L), “CPT codes 93040–93042 describe diagnostic rhythm ECG testing. They shall not be reported for cardiac rhythm monitoring in any site of service.”
Additionally, the AMA CPT Manual specifes, “Codes 93040–93042 are appropriate only when an order for the test is triggered by an event, the rhythm strip is used to help diagnose the presence or absence of an arrhythmia, and a report is generated. There must be a specific order for an electrocardiogram or rhythm strip followed by a separate, signed, written, and retrievable report. These codes should not be used for reviewing telemetry monitor strips obtained from a monitoring system.”
REMINDER: Watch for New, Revised, and Deleted Codes in 2026
2026 is around the corner, and it brings many new, revised, and deleted codes. Be sure to use the applicable version of your coding books based on your dates of service to ensure you remain current and code accurately. For more information regarding these changes, please visit www.cms.gov.
Realigned Editing Systems Coming in 2026
Select Health will be transitioning to a new editing system that will better align our editing processes with standard coding practices and Select Health policies, ultimately improving consistency and accuracy of edits. The new platform is expected to launch in the first quarter of 2026.
Questions? Contact your Provider Relations representative.
Questions?
Contact us with any questions about the content of Select Health medical and coding/reimbursement policies.