Effective September 1, 2024, prior authorization will be removed from 95805: Multiple sleep latency or maintenance of wakefulness testing, recording, analysis, and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness for Medicare only.
CPT 37242 as defined as Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (e.g., congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms).
CPT 37243 is defined as Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction.
Vitamin-D Testing – Effective September 1, 2024, the policy will be added as applicable to biomarker testing related to the state mandate, R.I.G.L. §27-19-81 for commercial products only. Please refer to the appropriate benefit booklet to determine whether the member’s plan has customized benefit coverage. Effective September 1, 2024, also refer to the Biomarker Testing Mandate and Genetic Testing Services policies for more details related to the services addressed in this policy, which will continue to be covered, when filed with covered diagnosis listed in the policy, for Medicare Advantage plans and commercial products. For additional details related to this policy, please click here.
Genetic Testing Services
Effective September 1, 2024, for Medicare Advantage plans and commercial products, there will be some modifications to authorization requirements for some CPT codes in the Genetic Testing Services policy. Prior authorization is no longer needed for CPT codes 81219, 81279, 81338, and 81339 when filed with diagnosis codes D45, D47.3, and D75.1. The need for prior authorization remains in place when these CPT codes are filed with any other diagnosis code. Additionally, the Vitamin-D Testing policy has been added as related, and the codes referenced in the Vitamin-D Testing policy have been included in the Genetic Testing Services code grid. For additional details related to this policy, please click here.
Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA)
Effective September 1, 2024, for Medicare Advantage plans and commercial products, there will be some modifications to authorization requirements for some CPT codes in the Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA) policy. Prior authorization is no longer needed for CPT code 0027U when filed with diagnosis codes D45, D47.3, and D75.1. Additionally, prior authorization is no longer needed for CPT code 0048U when filed with select diagnosis codes for non-small cell lung cancer and metastatic colorectal cancer. The need for prior authorization remains in place when these CPT codes are filed with any other diagnosis code. For additional details related to this policy, please click here.
Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms
Effective September 1, 2024, for Medicare Advantage plans and commercial products, there will be some modifications to authorization requirements for some CPT codes in the Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms policy. Prior authorization is no longer needed for CPT codes 81445 and 81449 when filed with select diagnosis codes for non-small cell lung cancer and metastatic colorectal cancer. Additionally, prior authorization is no longer needed for CPT codes 81457, 81458, 81462, and 81463 when filed with select diagnosis codes for metastatic colorectal cancer. The need for prior authorization remains in place when these CPT codes are filed with any other diagnosis code. For additional details related to this policy, please click here.
Acute Inpatient Rehabilitation Level of Care
Effective August 1, 2024, language in the Acute Inpatient Rehabilitation Level of Care medical policy is being clarified to include more language directly from the Medicare Benefit Policy Manual. Most specifically, language has been added to the Medical Criteria section of the policy to aid in clarifying when acute inpatient rehabilitation level of care may be determined to be medically necessary. It is strongly recommended that providers review the policy in its entirety. For additional details related to this policy, please click here.
Surgical Treatments for Lymphedema and Lipedema
Effective August 1, 2024, prior authorization for liposuction, excision and debulking for the treatment of lipedema will be required for Medicare Advantage Plans and recommended for Commercial Products and will be approved when the medical criteria in the policy is met. There will also be a minor revision to the medical criteria for Lymphedema treatments (lymph node transplant, lymphovenous bypass, and debulking of a limb) for Medicare Advantage Plans and Commercial Products. For additional details related to this policy, please click here.