Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease              

Effective 1 de julho, 2025, CPT codes 0119U and 0052U will be added to this policy, and it will change from requiring prior authorization for Medicare Advantage plans to not covered, and will remain not medically necessary for commercial products. For additional information related to this policy, please click here.     

Phototherapy for the Treatment of Seasonal Affective Disorder 

Effective 1 de julho, 2025, HCPCS code E0203 will change from not covered to covered for Medicare Advantage plans and will remain covered for commercial products. For additional information related to this policy, please click here.     

Serum Tumor Markers for Breast and Gastrointestinal Malignancies 

Effective 1 de julho, 2025, ICD-10 code C84.7B will be added to the list of covered ICD-10 codes for CPT code 86300 for commercial products. There will be no other changes for remaining tests in this policy. For additional information related to this policy, please click here.     

Molecular Testing for the Management of Pancreatic Cysts and Solid Pancreaticobiliary Lesions (Formerly Known as Molecular Testing for the Management of Pancreatic Cysts, Barrett Esophagus, and Solid Pancreaticobiliary Lesions)   

Effective 1 de julho, 2025, the BarreGen test will be moved to new medical policy, Adjunctive Techniques for Screening, Surveillance, and Risk Classification of Barrett Esophagus and Esophageal Dysplasia for Medicare Advantage plans and commercial products. For additional information related to this policy, please click here.     

Genetic Testing Services                                                       

Effective 1 de julho, 2025, the following change(s) will take place:  

• CPT codes 81347, 81348, 81353, for Medicare Advantage plans and commercial products, medical necessity review will change to using criteria in the Genetic Testing Services policy. 

For additional information related to this policy, please click here.     

Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA)                                                                                                

Effective 1 de julho, 2025, the following change(s) will take place:  

• CPT codes 0260U, 0264U, 0265U, 0266U, 0267U, 0343U, for commercial products, medical necessity review will change to using criteria in the Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA) policy.
• CPT codes 0347U, 0348U, 0349U, 0350U, for Medicare Advantage plans, medical necessity review will change to using InterQual content. Additionally, for Medicare Advantage plans and commercial products, prior authorization will not be needed for diagnosis codes F01-F99.
• CPT codes 0101U, 0102U, 0103U, 0129U, prior authorization will be removed for Medicare Advantage plans and commercial products and code will be allowed with specific diagnosis codes that support medical necessity. 
• CPT code 0209U, for Medicare Advantage plans and commercial products, prior authorization will not be needed for diagnosis codes F01-F99.
• CPT code 0261U, for commercial products, medical necessity review will change to using criteria in the Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA) policy.
• CPT code 0471U, for Medicare Advantage plans and commercial products, medical necessity review will change to using criteria in the Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA) policy.
• For the following CPT codes, for Medicare Advantage plans, medical necessity review will change to using InterQual content: 0009U, 0017U, 0023U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0138U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 0169U, 0171U, 0212U, 0213U, 0234U, 0235U, 0237U, 0238U, 0252U, 0273U, 0286U, 0306U, 0307U, 0332U, 0338U
• CPT code 0007U, prior authorization will be removed from Medicare Advantage Plans and Commercial Products and the service will change to covered.

For additional information related to this policy, please click here.

Prior Authorization Cardiology and Radiology Services

Effective 15 de maio, 2025, prior authorization requests for certain services may not be needed when the requesting physician is a Primary Care Provider. 

For additional information related to this policy, please click here. 

Prior Authorization via Web-Based Tool for Procedures 

Effective 15 de maio, 2025, prior authorization requests for sleep study services may not be needed when the requesting physician is a Primary Care Provider. 

For additional information related to this policy, please click here.