BCBS‑LA (AHS‑G2121) — Fecal Calprotectin Preferred; Serologic/Genetic Tests Not Covered

Effective 03/15/2026, BCBS Louisiana’s AHS‑G2121 policy designates fecal calprotectin as the preferred fecal biomarker for distinguishing IBD from noninflammatory GI disease and for monitoring IBD therapy response or relapse; when both fecal calprotectin and fecal lactoferrin are ordered concurrently, only fecal calprotectin will be approved. Fecal calprotectin or lactoferrin meet coverage criteria only for (a) differentiating IBD from noninflammatory conditions (e.g., IBS) and (b) monitoring known IBD; all other uses do not meet coverage criteria. Serologic markers, genetic tests, multianalyte serum panels, and combinatorial serologic‑genetic algorithms (e.g., Prometheus®, IBSchek®, etc.) are expressly non‑covered due to insufficient evidence of clinical utility. The policy aligns with AGA/ACG/ECCO/NICE/BSG guidance favoring fecal calprotectin while advising against routine serologic/genetic testing for IBD diagnosis or classification.

Cigna: Tremfya IV Induction (200 mg x3) and SC Maintenance — Mar 2026

Effective March 15, 2026, Cigna now authorizes Tremfya IV induction for adults (≥18) with moderate to severe Crohn’s disease or ulcerative colitis using a three-dose 200 mg IV regimen at Weeks 0, 4, and 8, with subsequent transition to subcutaneous maintenance. Approved SC maintenance options after IV induction are 100 mg at Week 16 then every 8 weeks, or 200 mg at Week 12 then every 4 weeks, with guidance to use the lowest effective maintenance dose. A three‑dose SC induction (400 mg at Weeks 0, 4, and 8) is also acceptable and follows the same SC maintenance schedules. The policy aligns coverage with FDA indications, requires gastroenterologist involvement, and references 2024–2025 ACG/AGA guidance placing IL‑23 inhibitors among recommended advanced therapies for induction and maintenance.

NJ: UnitedHealthcare Enteral Nutrition Criteria for Oral Specialized Formulas (Mar 2026)

UnitedHealthcare NJ updated its Enteral Nutrition policy (CS136NJ.O) effective 2026-03-01 to define explicit medical necessity criteria for oral Specialized Nutrient Formulas (Medical Foods). Coverage requires prescription by an authorized clinician or dietitian, a chronic condition with inability to meet needs by diet alone, use of a condition-specific medical food, and presence of an enumerated qualifying diagnosis (e.g., Crohn’s disease, severe malabsorption syndromes, eosinophilic esophagitis, inborn errors of metabolism, malnutrition). The policy cites evidence supporting use of exclusive/partial enteral nutrition and elemental diets for Crohn’s disease and EoE but distinguishes severe, medically necessary allergic conditions from mild food intolerances that are not covered. Readers are directed to related Benefit Considerations and a NJ durable medical equipment/supplies policy for coordination of coverage and exclusions.

Infliximab Dosing/Continuation Criteria Updated for GI Indications — Mar 2026

Effective March 15, 2026, Cigna’s IP0660 policy clarifies infliximab dosing and approval pathways for Crohn’s disease, ulcerative colitis, and indeterminate colitis by separating initial-therapy vs. continuation (currently receiving) criteria. Initial therapy generally follows induction at weeks 0, 2, and 6 with maintenance most commonly no more frequently than every 8 weeks and initial approvals for 6 months; continuation approvals require objective or symptomatic benefit and are issued for 1 year. For patients already on infliximab, maximum dosing is specified as up to 10 mg/kg IV no more frequently than every 4 weeks across indications, with some indication-specific maintenance options (every 6 or 4 weeks) noted. Guideline references (ACG, AGA, NCCN, EULAR, AAD/NPF, etc.) are cited to support indication-specific placement and non-gastroenterology dosing exceptions (e.g., immunotherapy-related toxicities, HS, Behçet’s).

Cigna: Adalimumab NDCs Non‑Covered; Crohn’s Initial‑Therapy Criteria Narrowed

Effective 2026-03-15 Cigna designates specific adalimumab products (including listed NDC ranges for adalimumab-bwwd, adalimumab-ryvk, Amjevita, Humira, and Hyrimoz) as Non‑Covered for Employer and Individual plans. Crohn’s disease initial‑therapy criteria were narrowed by removing prior systemic corticosteroid trial/contraindication, the requirement/option of a conventional systemic therapy trial, fistulizing disease and prior ileocolonic resection as approval routes. Initial approvals for adalimumab are age‑based (Crohn’s: ≥6 years; UC: ≥5 years) for 6 months when prescribed by or in consultation with a gastroenterologist; established patients (≥6 months on therapy) may receive 1‑year renewals with documented objective improvement or symptom improvement. The policy cites recent ACG/AGA guidance supporting upfront use of advanced therapies/TNF inhibitors and clarifies limited evidence for adalimumab efficacy in UC after prior TNFi failure.

CPT 81335 (TPMT) Code List Updated — Crohn’s Disease (K50.00) Included

UnitedHealthcare’s March 1, 2026 revision to MMP391.16 adds and clarifies ICD code applicability for CPT 81335 (TPMT) testing, explicitly listing K50.00 (Crohn’s disease of small intestine without complications) alongside hematologic malignancy, transplant status, and autoimmune diagnosis codes. The excerpt is a code-only update—no clinical criteria, coverage limits, or rationale are provided. Several hematologic codes show past deletion effective dates (notably 07/12/2025), indicating prior temporal changes to the code list. Providers should use the updated code list when billing CPT 81335 but review full policy for any clinical or coverage guidance not included in this excerpt.

Cigna Update: Enumerated Vitamin D Testing Indications, Limits & Exclusions

Effective 6/15/2026, Cigna’s Vitamin D Testing policy (0526) defines explicit, enumerated medical-necessity indications for total 25(OH)D (CPT 82306/0038U) and for active 1,25(OH)2D (CPT 82652), and sets repeat-testing limits. Total 25(OH)D testing is authorized only for listed conditions (e.g., rickets/osteomalacia, CKD, malabsorption, hyperparathyroidism, granulomatous disease, certain medications, extremes of age, prior deficiency, toxicity, specified genetic disorders), with repeat testing allowed only every 3 months when criteria are met. Active 1,25(OH)2D testing is limited to separate, specific indications (e.g., CKD, phosphate-wasting disorders, oncogenic osteomalacia, granulomatous or inflammatory diseases), and combined billing of both assays is expressly not covered. The policy reiterates that vitamin D testing for general population screening or unlisted indications is not covered; coverage decisions remain subject to plan language and applicable law.

Rinvoq Coverage Consolidation for IBD: 6‑Month Starts, 1‑Year Continuations

The March 15, 2026 revision to Cigna’s MDC 06 (IP0682) consolidates Rinvoq (upadacitinib ER tablets) coverage criteria for Crohn’s disease and ulcerative colitis, clarifying 6-month approvals for new starts and 1-year approvals for established therapy (≥6 months). Initial approvals require adults (≥18) to have an inadequate response to, or intolerance of, a 3-month trial of at least one TNF‑alpha inhibitor, and prescribing must involve a gastroenterologist. Continued coverage requires objective evidence of benefit (e.g., fecal calprotectin, CRP, imaging, endoscopy, or corticosteroid dose reduction) or documented symptomatic improvement versus baseline. Rinvoq oral solution (LQ) is not an approved formulation under this policy; only extended‑release tablets are covered.

Cigna: Omvoh IV Induction Dosing & GI Prescriber Requirement (Mar 2026)

Cigna’s March 2026 update authorizes Omvoh IV as a three-dose induction series for adults with Crohn’s disease (900 mg IV at Weeks 0, 4, 8) and ulcerative colitis (300 mg IV at Weeks 0, 4, 8) and requires prescription by or in consultation with a gastroenterologist. The policy aligns with FDA-labeled induction dosing and documents manufacturer-recommended transitions to subcutaneous maintenance (Crohn’s: 300 mg SC at Week 12 then q4w; UC: 200 mg SC at Week 12 then q4w). Concurrent use of Omvoh IV with another biologic or a targeted synthetic oral small molecule for inflammatory conditions is explicitly not covered; conventional synthetic DMARDs are allowed. Guideline references (ACG/AGA 2024–2025) are cited to place Omvoh among recommended advanced therapies for moderate–severe IBD.

Cigna: Entyvio (vedolizumab) dosing, approval durations, and IV→SC switch clarified

Cigna’s Entyvio (vedolizumab) policy clarifies indications, dosing options, and approval durations for adults with moderately to severely active Crohn’s disease and ulcerative colitis, effective 2026-03-15. Initial therapy approvals are limited to 6 months (patient ≥18 and GI prescriber/consult), while patients already on Entyvio for ≥6 months may receive renewals up to 1 year when objective improvement or symptom benefit is documented. Authorized dosing includes standard IV induction (300 mg at Weeks 0, 2, 6) with maintenance no more frequently than every 8 weeks, an alternative 0/2 week induction, and switching to 108 mg SC every 2 weeks at Week 6 or any responding IV visit; established patients may escalate IV dosing to every 4 weeks if needed. The policy aligns with recent ACG/AGA guidance endorsing Entyvio as an upfront advanced therapy option and emphasizes steroid-sparing maintenance and documentation requirements for continued approvals.