Policies
P B F
Jul 1, 2025

Medical policy updates

Behavioral Health Outpatient Professional Services

Effective July 1, 2025, clarifications for provider specialties have been made for the services addressed in this policy for Medicare Advantage plans and commercial products. For additional details related to this policy, please click here.     

Transcranial Magnetic Stimulation (TMS)    

Effective September 1, 2025, coverage for TMS will change from covered to covered only when filed with a covered ICD-10 code for the CPT codes contained in the policy for Medicare Advantage plans and commercial products.  For additional details related to this policy, please click here.     

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer            

Effective July 1, 2025:

  • CPT codes 81518 – 81523 will continue to be covered when filed with a covered ICD-10 code for Medicare Advantage plans and commercial products; however, coverage guidance will be moved from this medical policy to medical policy Genetic Testing Services.  
  • CPT code 0045U will continue to require prior authorization; however, the medical criteria will move from this policy to being available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. Coverage guidance will be available in the medical policy Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA). 
  • There are no other changes for the remaining test(s) in this medical policy for Medicare Advantage plans or commercial products.

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

Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management           

Effective September 1, 2025: 

  • CPT code 81541 will continue to require prior authorization; however, the medical criteria will move from this policy to being available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. Coverage guidance will be available in the medical policy Genetic Testing Services.
  • CPT code 81542 will continue to require prior authorization; however, the medical criteria will move from this policy to being available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. Additional medical criteria were identified for this service and will also be available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. Coverage guidance will be available in the medical policy Genetic Testing Services. The test name will be revised in the medical policy to Decipher Prostate Genomic Classifier to address the uses of Decipher before and after radical prostatectomy. As a result, Decipher RP will no longer be addressed as a separate test.
  • CPT code 0047U will continue to require prior authorization; however, the medical criteria will move from this policy to being available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. Coverage guidance will be available in the medical policy Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA). 
  • Oncotype DX AR-V7 Nuclear Detect (CPT code 81479) will continue to require prior authorization; however, the medical criteria will move from this policy to being available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. Coverage guidance will be available in the medical policy Genetic Testing Services.
  • There are no other changes for the remaining test(s) in this medical policy for Medicare Advantage plans or commercial products.

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

Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer

Effective July 1, 2025: 

  • CPT codes 81539 and 81551 will continue to require prior authorization; however, the medical criteria will move from this policy to being available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. Coverage guidance will be available in the medical policy Genetic Testing Services. 
  • CPT code 0339U will continue to require prior authorization; however, the medical criteria will move from this policy to being available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. Coverage guidance will be available in the medical policy Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA). 
  • There are no other changes for the remaining test(s) in this medical policy for Medicare Advantage plans or commercial products.

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

Prostate Cancer Detection with IsoPSA     

CPT code 0359U will continue to require prior authorization; however, the medical criteria will move from this policy to being available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. Coverage guidance will be available in the medical policy Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA).

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

Genetic Testing Services

Prior authorization will be removed from CPT codes 81175 and 81176 for Medicare Advantage plans and commercial products. The codes will be medically necessary when filed with a covered ICD-10 code identified in the policy.

  • Prior authorization will be removed from CPT codes 81284, 81286, and 81289 for Medicare Advantage plans. The services will change to not covered.
  • CPT codes 81173, 81174, 81204, 81220, 81221, 81222, 81223, 81224, 81329, 81336, and 81337 will not require authorization for Medicare Advantage plans and commercial products when filed with ICD-10-CM diagnosis codes Z13.79 and Z14.1, in addition to several other ICD-10-CM diagnosis codes already identified in the policy.
  • CPT code 81162 will need authorization for commercial products when not filed with the diagnosis codes identified in this policy.

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

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

Effective September 1, 2025:  

  • CPT code 0236U will not require authorization for Medicare Advantage plans and commercial products when filed with several ICD-10-CM diagnosis codes identified in the policy. Authorization is required for Medicare Advantage plans and recommended for commercial products when filed with all other diagnosis codes, and will follow InterQual criteria in the online authorization tool.
  • Prior authorization will be removed from CPT codes 0248U and 0435U for Medicare Advantage plans and commercial products. The codes will be not covered for Medicare Advantage plans and not medically necessary for commercial products.
  • Prior authorization will be removed from CPT code 0062U for Medicare Advantage plans. The code will be not covered for Medicare Advantage plans.
  • For CPT codes 0094U and 0368U, for Medicare Advantage plans, medical necessity review will change to using InterQual content. 
  • Prior authorization will be removed from CPT codes 0402U and 0455U for Medicare Advantage plans and commercial products. The codes will be medically necessary when filed with a covered ICD-10 code identified in the policy.
  • CPT codes 0105U, 0369U and 0407U will continue to require prior authorization; however, the medical criteria used for review will change to Centers for Medicare and Medicaid Services (CMS) Local Coverage Determination (LCD) guidelines available in the online authorization tool. 
  • CPT codes 0523U and 0543U will continue to require prior authorization; however, the medical criteria used for review will change to Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (LCD) guidelines available in the online authorization tool. 

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

Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies 

Effective September 1, 2025: 

  • CPT codes 0022U, 0037U, 0111U, 0172U, 0242U, 0239U, and 0473U will continue to require prior authorization; however, the medical criteria will move from this policy to being available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. Coverage guidance will be available in the medical policy Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA).
  • CPT 0211U will change from not covered for Medicare Advantage plans and not medically necessary for commercial products, to requiring prior authorization using the medical criteria available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. Coverage guidance will be available in the medical policy Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA). 
  • There are no other changes for the remaining test(s) in this medical policy for Medicare Advantage plans or commercial products.

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

Envisia for Idiopathic Pulmonary Fibrosis

Effective September 1, 2025: 

  • CPT code 81554 will continue to require prior authorization; however, the medical criteria will move from this policy to being available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. Additional medical criteria were identified for this service and will also be available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. Coverage guidance will be available in the medical policy Genetic Testing Services.

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

Anastomosis of Extracranial-Intracranial Arteries

Effective September 1, 2025: 

  • CPT 61711 will no longer require authorization for Medicare Advantage plans and commercial products. 

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

Back to Provider Update