InterQual updates 

Effective February 1, 2026, updates will be made in the online authorization tool for the following InterQual criteria:

CP: Molecular diagnostics subsets

• Alzheimer’s Disease
• DPYD Testing for Fluoropyrimidines Toxicity

Effective March 1, 2026, updates will be made in the online authorization tool for the following InterQual criteria:

CP: Procedures

• Radiofrequency Ablation (RFA) or Cryoablation, Renal

CP: Durable Medical Equipment

• Bone Growth Stimulators, Noninvasive

CP: Molecular Diagnostics subsets

• HBA1 and HBA2 Testing for Alpha Thalassemia
• Lynch Syndrome (LS)
• Prognostic and Predictive testing for Colorectal Cancer

Expanded fertility services                                                   

Effective April 1, 2026, for self-funded employer expanded fertility coverage:

1. EmbryoGlue will be added to the policy and will be considered not medically necessary.
2. Medical criteria for reciprocal in-vitro fertilization will be added to the policy.
3. The definition of infertility will be revised:
   • Will no longer include the need for medicated artificial insemination (AI) (intra-cervical insemination (ICI) or artificial intrauterine insemination (IUI)) cycles.
   • Other documented infertility causes will be added.
   • Home AI (IUI or ICI) will be not covered. 

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

Infertility services     

Effective April 1, 2026, for commercial products and Medicare Advantage plans: 

1. EmbryoGlue will be added to the policy and will be not covered for Medicare Advantage plans and not medically necessary for commercial products.
2. When the medical necessity criteria for iatrogenic infertility have been met, claims for multiyear storage, or storage over 12 months, will be not covered as claims are only covered up to one year (12 months) per benefit year.
3. The eligibility criteria will be revised as follows:

• Artificial insemination (AI) [intra-cervical insemination (ICI) or artificial intrauterine insemination (IUI)] cycles will change to covered.
• The number of required AI (ICI or IUI) cycles will be reduced to three cycles, and the requirement for medicated AI (ICI or IUI) cycles will be eliminated. 
• Other documented infertility causes will be added.
• Home AI (IUI or ICI) will be not covered. 

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

Acute Hepatitis Panel

Effective April 1, 2026, for CPT 80074, the covered diagnosis list will be updated to include diagnosis codes R10.20 – R10.24 and to remove diagnosis code R10.2 because it is no longer valid. For additional details related to this policy, please click here. 

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

Effective April 1, 2026:   

• CPT 0046U, 0049U, 0050U, 0060U, 0153U: Medical necessity criteria will change to InterQual criteria and will be available in the online authorization tool for participating providers for Medicare Advantage plans.
• CPT 0117U, 0179U, 0229U, 0313U, 0315U, 0466U, 0525U: Prior authorization will be removed, and the service will change to not covered for Medicare Advantage plans and not medically necessary for commercial products.
• CPT 0444U and 0530U: Medical necessity criteria will change to InterQual criteria and will be available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.
• CPT 0027U will not require authorization for Medicare Advantage plans and commercial products when filed with 31 ICD-10-CM diagnosis codes in addition to 3 ICD-10-CM diagnosis codes already identified in the policy.

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

Genetic Testing Services

Effective April 1, 2026:   

• CPT 81190: Medical necessity criteria will change to InterQual criteria and will be available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products.
• CPT 81315 and 81316: A covered diagnosis edit will be applied to Medicare Advantage plans and commercial products and prior authorization will be removed.
• CPT 81345: Prior authorization will not be needed for Medicare Advantage plans and commercial products for diagnosis codes C71.0 – C71.9.
• CPT 81220 will not require authorization for Medicare Advantage plans and commercial products when filed with ICD-10-CM diagnosis code E84.8, in addition to several other ICD-10-CM diagnosis codes already identified in the policy.
• CPT 81270 and 81279 will not require authorization for Medicare Advantage plans and commercial products when filed with 31 ICD-10-CM diagnosis codes in addition to 3 ICD-10-CM diagnosis codes already identified in the policy.

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

Minimally Invasive Procedures for Back Pain 

Effective April 1, 2026, for CPTs 64628/64629, prior authorization will be recommended utilizing the medical necessity criteria in this policy for commercial products. Prior to April 1, 2026, services are not medically necessary for commercial products. Additional revisions were made to the medical criteria in this policy for both Medicare Advantage plans and commercial products, effective April 1, 2026. For additional details related to this policy, please click here. 

Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome 

Effective April 1, 2026, CPT 64568 will be added to this policy where it will continue to require prior authorization, and it will utilize the medical necessity criteria in this policy for both Medicare Advantage plans and commercial products. CPT 64568 will utilize the medical necessity criteria in this policy when intended for a hypoglossal nerve stimulator. Prior to April 1, 2026, 64568 will utilize medical necessity criteria for both Medicare Advantage plans and commercial products when intended for a hypoglossal nerve stimulator. No other changes were made to policy. For additional details related to this policy, please click here. 

Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease               

Effective April 1, 2026 for CPT codes 83700, 83701 and 83704 the covered diagnosis list has been updated to include ICD-10-CM codes E88.10 through E88.14 and E88.19 (replacing deleted ICD-10-CM code E88.1), and E78.010, E78.011, and E78.019 (replacing deleted ICD-10-CM code E78.1) for Medicare Advantage plans and commercial products. For additional details related to this policy, please click here. 

Chelation Therapy for Off-Label Uses 

Effective April 1, 2026, for CPT S9355, covered diagnosis list will be updated. Added E11.A, removed G35, and replaced with new range of G35.A-G35.D for commercial products. For additional details related to this policy, please click here. 

Glucose Monitoring – Continuous

Effective March 1, 2026, prior authorization will no longer be required for CPT codes 0446T, 0447T and 0448T for Medicare Advantage Plans or Commercial Products. For additional details related to this policy, please click here.

Removal of Implantable Devices                        

Effective March 1, 2026, prior authorization will no longer be required for CPT codes 0447T and 0448T for Medicare Advantage Plans or Commercial Products. For additional details related to this policy, please click here.