Molecular Testing in the Management of Pulmonary Nodules

Effective November 1, 2026 all CPT codes in this policy (0360U, 0080U, 0092U, 81479 representing Percepta® Bronchial Genomic Classifier) will now be addressed only in the medical policy Biomarker Testing Mandate, with no changes in coverage for Medicare Advantage plans or commercial products. For additional details related to this policy, please click here. 

Long Term Acute Care Hospital (LTACH) Admission and Transition of Care Criteria 

Effective November 1, 2026 the Policy Statement section will be updated to reflect that, for Medicare Advantage plans, “Medicare may change coverage or criteria.” All changes are effective when Medicare determines them to be so and are applicable to Medicare Advantage plan members and will supersede this policy.” For additional details related to this policy, please click here. 

Genetic Testing for Diagnosis and Management of Mental Health Conditions                              

Effective November 1, 2026, obsolete tests that are filed with CPT code 81479 will be removed from this policy. The OptimalRx Plus® (Dynacare Plus), filed with CPT code 81479, will be added to the policy [replacing obsolete test, Genecept Assay (Genomind, Inc.)] and will be not covered for Medicare Advantage plans and not medically necessary for commercial products. For additional details related to this policy, please click here.

Joint Replacement, Shoulder

Effective November 1, 2026 prior authorization will continue to be required for Medicare Advantage Plans and recommended for Commercial Products for CPT codes 23470 and 23472 utilizing revised medical criteria in this new policy instead of the existing medical criteria in the online authorization tool. For additional details related to this policy, please click here.

ProMark® Risk Score (formerly Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management)

Effective November 1, 2026, this policy will now address only the ProMark® Risk Score, filed with CPT code 81479, with no change in coverage. For additional details related to this policy, please click here.

Prior Authorization of Services, Treatments or Procedures 

Effective October 1, 2026, prior authorization will be removed for in-lab sleep studies (CPT codes 95805, 95808, 95810, 95811) for Commercial Products. For additional details related to this policy, please click here.