Prior Authorization via Web Based Tool for Durable Medical Equipment (DME)                  

Effective 1 de marzo de 2025, prior authorization will be recommended for commercial products for HCPCS code E2298 utilizing the medical necessity criteria in the online authorization tool, which is a change from not covered for commercial products. There are no changes for Medicare Advantage plans. HCPCS code E2513 will be removed from the New Technology and Miscellaneous Services policy , and will be added to this policy and will continue to require prior authorization for Medicare Advantage plans utilizing medical criteria in the online authorization tool; and will change from not medically necessary to prior authorization recommended for commercial products utilizing medical criteria in the Medical Necessity policy. Effective 1 de marzo de 2025, prior authorization will no longer be required for Medicare Advantage plans and will no longer be recommended for commercial products for HCPCS codes E0651, E0668, E0669, and E0183. For additional details related to this policy, please click here. 

New Technology and Miscellaneous Service

Effective 1 de marzo de 2025, HCPCS code E2513 will be removed from this policy and will be added to the Prior Authorization via Web Based Tool for Durable Medical Equipment (DME)policy, and will continue to require prior authorization for Medicare Advantage plans utilizing medical criteria in the online authorization tool; and will change from not medically necessary to prior authorization recommended for commercial products utilizing medical criteria in the Medical Necessity policy. For additional details related to this policy, please click here.

Prior Authorization via Web Based Tool for Procedures

Effective 1 de marzo de 2025, prior authorization will be required for Medicare Advantage plans and recommended for commercial products for CPT codes 27427, 29806, 29914, 29915, 29916, 93656, utilizing medical criteria in the online tool. Prior authorization will be removed from CPT codes 65730, 67800, 67840, and 67966. For additional details related to this policy, please click here.

Measurement of Serum Antibodies to Selected Biologic Agents 

Effective 1 de marzo de 2025, CPT codes 80145, 80230, 80280 will change to covered from not covered for Medicare Advantage plans and not medically necessary for commercial products. CPT code 84999 will have a change in medical necessity criteria for tests that are applicable to the measurement of serum antibodies to selected biologic agents. For additional details related to this policy, please click here.

Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer            

Effective 1 de marzo de 2025, CPT codes 0005U and 81313 will change from prior authorization to covered 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.

Molecular Markers in Fine Needle Aspiration of the Thyroid    

Effective 1 de marzo de 2025, the medical necessity criteria will be revised for CPT code 81546 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.

Molecular Testing in the Management of Pulmonary Nodules   

Effective 1 de marzo de 2025, CPT code 0360U will change from not covered to covered for Medicare Advantage plans and will change from not medically necessary to covered for commercial products. There will be no other changes to this policy. For additional details related to this policy, please click here.

Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies 

Effective 1 de marzo de 2025, CPT code 0448U will be added to the Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies medical policy. CPT code 0448U will continue to require prior authorization and will be considered medically necessary for both Medicare Advantage plans and commercial products when the medical criteria is met. There will be no other changes to this policy. For additional details related to this policy, please click here.

Total Joint Arthroplasty – Hip and Knee 

Effective 1 de marzo de 2025, the medical necessity criteria will be revised for the following sections of the Total Joint Arthroplasty-Hip and Knee medical policy: Initial Total Knee Arthroplasty, Replacement/Revision Knee Arthroplasty, and Replacement/Revision Hip Arthroplasty for commercial products only. There are no coding changes and there will be no other changes to this policy. For additional details related to this policy, please click here.

Evaluation of Biomarkers for Alzheimer’s Disease 

Effective 1 de marzo de 2025, the following codes 0358U/0459U will be added to this policy and will require prior authorization based on new medical criteria in this policy for both Medicare Advantage plans and commercial products. Effective 1 de marzo de 2025, CPT 0445U will change from not covered for Medicare Advantage plans and not medically necessary for commercial products to requiring prior authorization and will be reviewed using the medical criteria in the policy. Additionally, effective 1 de marzo de 2025, CPT 0443U will change from not covered for Medicare Advantage plans and not medically necessary for commercial products for all indications to not covered for Medicare Advantage plans and not medically necessary for commercial products with an ICD-10 diagnosis edit. There will be no other changes to this policy. For additional details related to this policy, please click here.

Laboratory Tests Post Transplant and for Heart Failure 

Effective 1 de marzo de 2025, the medical necessity criteria in the policy will be revised for both Medicare Advantage plans and commercial products. 

Additionally, there will be the following coding changes effective 1 de marzo de 2025:

For Medicare Advantage plans:

• The AlloMap test (CPT 81595) will change from covered to requiring prior authorization using the medical criteria in the Laboratory Tests Post Transplant and for Heart Failure policy for Medicare Advantage plans.
• The Allosure Lung test (CPT 81479) will change from not covered for Medicare Advantage plans to requiring prior authorization and will be considered medically necessary for Medicare Advantage plans when the medical criteria in the policy is met.
• The HeartCare test (CPT 81479) will change from covered for Medicare Advantage plans to requiring prior authorization and will be considered medically necessary for Medicare Advantage plans when the medical criteria in the policy is met.
• The Prospera test (CPT 0493U) will change from requiring prior authorization using the medical criteria in the policy to not covered for Medicare Advantage plans.

For commercial products:

• The AlloMap test (CPT 81595) will change from requiring prior authorization using Interqual to requiring prior authorization using the medical criteria in the Laboratory Tests Post Transplant and for Heart Failure policy for commercial products.
• The Allosure Lung test (CPT 81479) will change from not medically necessary to requiring prior authorization and will be considered medically necessary for commercial products when the medical criteria in the policy is met.
• The HeartCare test (CPT 81479) will change from covered for commercial products to requiring prior authorization and will be considered medically necessary when the medical criteria in the policy is met.
• The Prospera test (CPT 0493U) will change from requiring prior authorization using the medical criteria in the policy to not medically necessary for commercial products.

There are no other coding changes and there will be no other changes to this policy. For additional details related to this policy, please click here.

Genetic testing services                                                         

Effective 1 de marzo de 2025, the following changes will take place: 

• For CPT codes 81171, 81172, and 81441 and HCPCS codes S3865 and S3866, for Medicare Advantage plans and commercial products, medical necessity review will change to using InterQual content.
• For CPT code 81218, for Medicare Advantage plans and commercial products, prior authorization will no longer be needed for specific diagnosis codes identified in the policy. Additionally, all other diagnosis codes will continue to need prior authorization, however, the review will change to using the criteria in this policy. 
• For CPT code 81235, for Medicare Advantage plans and commercial products, prior authorization will no longer be needed. Coverage will change to medically necessary with specific diagnosis codes, all other diagnosis codes will be not covered for Medicare Advantage plans and not medically necessary for commercial products. 
• For CPT code 81313, coverage will change to covered for Medicare Advantage plans and commercial products.
• For CPT code 81595, coverage for Medicare Advantage plans will change to prior authorization using medical criteria in the Laboratory Post Transplant and for Heart Failure policy. Additionally, prior authorization review for commercial products will change to review using medical criteria in the Laboratory Post Transplant and for Heart Failure policy.

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

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

Effective 1 de marzo de 2025, the following changes will take place: 

• For CPT codes 0005U and 0360U, coverage for Medicare Advantage plans and commercial products will change to a covered service.
• For CPT code 0179U, for Medicare Advantage plans, medical necessity review will change to review using InterQual content. 
• For CPT code 0288U, for Medicare Advantage plans and commercial products, medical necessity review will change to review using criteria in the new policy, Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer.
• For CPT codes 0358U and 0459U, medical criteria used for medical necessity review will change to using criteria in the Evaluation of Biomarkers for Alzheimer’s Disease policy.
• For CPT code 0445U, for Medicare Advantage plans and commercial products, coverage will change to prior authorization using medical necessity criteria found in the Evaluation of Biomarkers for Alzheimer’s Disease policy.
• For CPT code 0414U, for Medicare Advantage plans and commercial products, medical necessity review will change to using the criteria in this policy. 
• For CPT code 0448U, for Medicare Advantage plans and commercial products, medical necessity review will change to review using criteria in the Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies policy,
• For CPT code 0461U, for Medicare Advantage plans and commercial products, prior authorization will no longer be needed for specific diagnosis codes identified in the policy. All other diagnosis codes will be reviewed using medical necessity criteria in this policy. 
• For CPT code 0493U, coverage will change to not covered for Medicare Advantage plans and not medically necessary for commercial products. 
• For CPT codes 0460U, 0471U, 0474U, 0475U, 0485U, 0486U, 0487U, 0496U, 0498U, and 0516U, for Medicare Advantage plans and commercial products, medical necessity review will change to review using InterQual content.

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

Infertility services    

Effective 1 de marzo de 2025, this policy will have multiple formatting revisions to enhance ease of use (e.g., Table of Contents, intra-policy links, re-ordering of policy sections, and reformatting of the Coding section of the policy), and clarifications throughout policy (e.g., explanation of Eligibility Criteria versus Medical Criteria, addition of a policy section for Definitions). Medical criteria will be added for reciprocal in-vitro fertilization and artificial insemination cycles (intrauterine and intracervical). Eligibility criteria will also include medical necessity criteria related to microsurgical epididymal sperm aspiration, testicular sperm extraction or aspiration.

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

Long Term Acute Care Hospital (LTACH)

Skilled Nursing Facilities

Acute Inpatient Rehabilitation Level of Care    

Effective 15 de marzo de 2025, for Medicare Advantage Plans, a post-acute care vendor has been delegated to perform utilization management services for admission, concurrent, and retrospective requests according to this policy, except for members who are attributed to a Prospect Primary Care Provider. Refer to the associated policies for additional information.