Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease
Effective February 1, 2026, CPT codes 85384 and 85385 will change from being not covered for Medicare Advantage plans and not medically necessary for commercial products to covered for Medicare Advantage plans and commercial products. For CPT code 82610, several additional covered ICD-10 codes have been added for Medicare Advantage plans and commercial products. For additional details related to this policy, please click here.
Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions
Effective February 1, 2026, for HCPCS code G0465, several additional covered ICD-10-CM codes have been added for Medicare Advantage plans and commercial products. For additional details related to this policy, please click here.
Allergy Testing
Effective February 1, 2026, for CPT codes 86003 and 86008, several additional covered ICD-10 codes have been added for Medicare Advantage plans and commercial products. For CPT code 83516, several additional non-covered ICD-10 codes have been added for Medicare Advantage plans and commercial products. For additional details related to this policy, please click here.
Oral Nutrition Mandate
Effective February 1, 2026, the medical criteria for oral nutrition will include milk/soy protein allergy for infants (0-12 months) with failure to thrive AND blood in the stools for commercial products only. For additional details related to this policy, please click here.
Mastectomy Treatment, Breast Reconstruction and Hospital Stays Mandate
Effective February 1, 2026, CPT code 97530 will be added to the policy to allow at no cost share to members with a commercial product. For additional details related to this policy, please click here.
Miscellaneous Vascular Embolization Procedures
Effective February 1, 2026, there will be revisions to the Medical Criteria and Policy Statement sections of the policy for Medicare Advantage plans and commercial products. For additional details related to this policy, please click here.
Molecular Markers in Fine Needle Aspiration of the Thyroid
Effective February 1, 2026, CPT code 0287U will change from utilizing medical criteria in this policy to medical criteria in the online authorization tool for Medicare and commercial. All other tests in this policy will change from requiring prior authorization to covered for Medicare Advantage plans and commercial products. Please refer to the draft medical policy for details. For additional details related to this policy, please click here.
Digital Health Therapies – Therapeutic Applications
Effective February 1, 2026, CPT A9291 will change from being not medically necessary to being a non-covered/contract exclusion for commercial products only. There will be no other changes in this medical policy. For additional details related to this policy, please click here.
Digital Health Technologies for Attention Deficit/Hyperactivity Disorder
Effective February 1, 2026, CPT A9291 will change from being not medically necessary to being a non-covered/contract exclusion for commercial products only. There will be no other changes in this medical policy. For additional details related to this policy, please click here.
Risk Reducing Mastectomy
Effective February 1, 2026, The Risk Reducing Mastectomy medical policy will change from being a medical policy to a payment policy. There will be no other changes in this medical policy. For additional details related to this policy, please click here.
Magnetic Resonance Imaging-Guided Focused Ultrasound
Effective February 1, 2026, services will continue to require prior authorization; however, the medical criteria used to determine medical necessity will change. CPT Code 61715 and HCPCS Code C9734 will be reviewed using the medical criteria found 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 February 1, 2026:
- CPT Codes 0552U – 0555U: medical necessity criteria will be changed to InterQual criteria and will be 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.
Pediatric Dental Services - Essential Health Benefit (P,F) Charlotte Flanagan
Effective January 1, 2026, January 2026 CDT code updates will be in effect for Commercial Products. There will be no other revisions for this medical policy. For additional details related to this policy, please click here.
Bronchial Valves
Effective February 1, 2026, insertion of endobronchial valves will change from being not covered for Medicare Advantage Plans and not medically necessary for Commercial Products to medically necessary for Medicare Advantage Plans and Commercial Products when medical necessity criteria in the policy are met. For additional details related to this policy, please click here.