Prior authorization of spinal procedures 

Effective September 1, 2026, prior authorization through the Spine Procedures vendor will be required for Medicare Advantage plans for 29 additional CPT codes. The additional CPT codes will also be reflected in medical policy, Prior Authorization of Services, Treatments or Procedures (below). For additional details related to this policy, please click here.

Prior Authorization of Services, Treatments or Procedures

Effective September 1, 2026, prior authorization will be required for Medicare Advantage plans for CPT codes 33285, 93228, and 93229 utilizing medical criteria in the online authorization tool. Prior authorization through the spine procedures vendor will be required for Medicare Advantage plans for 29 additional CPT codes, which will also be reflected in medical policy, Prior Authorization of Spinal Procedures (above). For additional details related to this policy, please click here.

Chelation therapy for off-label uses

Effective September 1, 2026 the following group of diagnosis codes have been added to the policy to represent the new off-label use of chelation therapy, Parkinson Disease: G20.A1-G20.A2, G20.B1-G2, G20.C,G21.4, and G21.8-G21.9. For additional details related to this policy, please click here.

Multimarker Serum Testing Related to Ovarian Cancer

Effective September 1, 2026, prior authorization will be required for Medicare Advantage plans and commercial products for CPT code 81503 utilizing medical criteria in the online authorization tool. For additional details related to this policy, please click here. 

Cochlear implants

Effective September 1, 2026, prior authorization will be required for commercial products for CPT code 69930 utilizing medical criteria 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, 2026, the criteria source for CPTs 0022U, 0037U, 0111U, 0172U, 0242U, 0239U, 0473U, and 0211U for both Medicare Advantage plans and commercial products will be found in the Biomarker Mandate policy grid and will no longer be in the Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies medical policy. For additional details related to this policy, please click here. 

Lung Liquid Biopsy

Effective August 1, 2026, CPT code 0388U 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, Biomarker Testing Mandate. For additional details related to this policy, please click here. 

Balloon Dilation of Eustachian Tube           

Effective September 1, 2026, the medical necessity criteria will be revised for CPT codes 69705 and 69706 for Medicare Advantage plans and commercial products. There will be no other changes to this policy. For additional details related to this policy, please click here. 

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis and Predict Therapeutic Response in Individuals with Breast Cancer

Effective September 1, 2026, the medical policy title will change from “Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer” to “Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis and Predict Therapeutic Response in Individuals with Breast Cancer.” Additionally, CPT 0045U will be removed from this policy and the criteria source can be found in the Biomarker Testing Mandate. There will be no other changes to this policy. For additional details related to this policy, please click here. 

Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders

Effective September 1, 2026, the medical necessity criteria will be revised for CPT codes 0214U and 0215U for Medicare Advantage plans and commercial products. Additionally, CPT codes 0425U and 0426U will be removed from this policy and the criteria source can be found in the Biomarker Testing Mandate. There will be no other changes to this policy. For additional details related to this policy, please click here. 

Biomarker Testing Mandate            

Effective September 1, 2026: 

• CPT codes 0198U and 0222U: Service will be covered for commercial products.
• CPT codes 81171, 81172, 81174, 81337, and 81362: Medicare Advantage plans will change to not covered and for commercial products, medical necessity criteria will change to the criteria in this policy.
• CPT codes 81190, 81221, and 0583U: Medical necessity criteria will change to the criteria in this policy for Medicare Advantage plans and commercial products.
• CPT code 81289: Medical necessity criteria will change to the criteria in this policy for commercial products.
• CPT codes 81443 and 0129U: Service will be covered for Medicare Advantage plans and commercial products.
• CPT codes 81504 and 0528U: Prior authorization will be added to Medicare Advantage plans and commercial products.

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