Laboratory Tests Post Transplant and for Heart Failure 

Effective August 1, 2025:   

• CPT codes 0540U, 81595, 0118U, 0508U, and 0509U 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 policies Genetic Testing Services and 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. 

Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer

Effective August 1, 2025:   

• CPT code 0288U 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 this medical policy for Medicare Advantage plans or commercial products. 

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

Mass Spectrometry (MS) Testing in Monoclonal Gammopathy 

Effective October 1, 2025, an additional 76 ICD-10 diagnosis codes will be added to the list of covered ICD-10 codes for CPT 0077U for Medicare Advantage plans and commercial products. No other changes were made to this policy. For additional details related to this policy, please click here.

Electrical Bone Growth Stimulation of the Appendicular Skeleton-Implantable and Semi-Implantable

Effective October 1, 2025, the Electrical Bone Growth Stimulation of the Appendicular Skeleton-Implantable and Semi-Implantable medical policy is being corrected to state that CPT 20975 requires prior authorization for Medicare Advantage plans, as has been stated in the prior authorization of spinal procedures policy. For additional details related to this policy, please click here.

Prognostic and Predictive Molecular Classifiers for Bladder Cancer   

Effective August 1, 2025: 

• CPT code 0016M 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 Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA).
• CPT codes 81445, 81449, 81457, 81458, 81462, 81463, and 0048U will continue to require prior authorization but will have their diagnosis edits removed. Additionally, the medical criteria for these codes 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 policies Genetic Testing Services and Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA).  
• CPT codes 81459, 81464, and 0250U 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 policies Genetic Testing Services and Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA). 
• CPT codes 81455 and 81456 will change from requiring prior authorization for Medicare Advantage plans and commercial products to being covered for Medicare Advantage plans and commercial products. Coverage guidance will be available in the medical policy Genetic Testing Services. 
• CPT code 81595: The location of medical necessity criteria will be updated to reflect criteria are available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.

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

Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms

Effective September 1, 2025: 

• CPT codes 81445, 81449, 81457, 81458, 81462, 81463, and 0048U will continue to require prior authorization but will have their diagnosis edits removed. Additionally, the medical criteria for these codes 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 policies Genetic Testing Services and Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA).  
• CPT codes 81459, 81464, and 0250U 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 policies Genetic Testing Services and Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA). 
• CPT codes 81455 and 81456 will change from requiring prior authorization for Medicare Advantage plans and commercial products to being covered 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.        

Transcatheter Mitral Valve Repair or Replacement

Effective October 1, 2025, clarifying language has been added to the policy statement for Transcatheter mitral valve-in-valve replacement (TMViVR). For additional details related to this policy, please click here.

Genetic Testing Services

Effective August 1, 2025:   

• CPT code 81595: The location of medical necessity criteria will be updated to reflect criteria are available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.

Effective September 1, 2025: 

• CPT codes 81445, 81449, 81457, 81458, 81462, 81463, and 0048U: Authorization will be needed for all diagnosis codes. Additionally, the location of medical necessity criteria will be updated to reflect criteria are available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.
• CPT codes 81459, 81464, and 0250U: The location of medical necessity criteria will be updated to reflect criteria is available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.
• CPT codes 81455 and 81456: The prior authorization requirement will be removed for Medicare Advantage plans and commercial products and the services will be covered. 

Effective October 1, 2025:

• CPT code 81479 when used to represent Percepta: The location of medical necessity criteria will be updated to reflect criteria is available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.
• CPT codes 0118U, 0508U, 0509U, and 0540U: The location of medical necessity criteria will be updated to reflect criteria are available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.
• CPT code 0016M: The location of medical necessity criteria will be updated to reflect criteria are available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.
• CPT code 288U: The location of medical necessity criteria will be updated to reflect criteria are available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.

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

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

Effective August 1, 2025:   

• CPT codes 0118U, 0508U, 0509U, and 0540U: The location of medical necessity criteria will be updated to reflect criteria are available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.
• CPT code 0016M: The location of medical necessity criteria will be updated to reflect criteria are available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.
• CPT code 288U: The location of medical necessity criteria will be updated to reflect criteria are available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.

Effective September 1, 2025: 

• CPT code 0048U: Authorization will be needed for all diagnosis codes. Additionally, the location of medical necessity criteria will be updated to reflect criteria are available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.
• CPT code 0250U: The location of medical necessity criteria will be updated to reflect criteria are available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.

Effective October 1, 2025:

• CPT code 0080U: The location of medical necessity criteria will be updated to reflect criteria are available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. 
• CPT codes 0403U, 0487U, and 0544U: The medical necessity 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 for participating providers for Medicare Advantage plans and commercial products.

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