The following tests, procedures, devices, and items require prior authorization. This consolidated list includes individual gene tests, molecular pathology procedures, genomic panels, Medicare procedure codes, durable medical equipment, drugs, injections, implants, and other services identified by the payer as subject to prior authorization.
Medicare procedure codes for molecular pathology, genomic sequencing, and related laboratory tests (examples): 0016U, 0018U, 0022U, 0031U, 0032U, 0045U, 0205U, 0209U, 0215U, 0236U, 0306U, 0332U, 0340U, 0347U, 0348U, 0349U, 0350U, 0405U, 0409U, 0410U, 0419U, 0424U, 0434U, 0440U, 0449U, 0454U, 0469U, 0481U, 0493U, 0494U, 0497U, 0498U, 0499U, 0500U, 0506U, 0523U, 0529U, 0536U, 0537U, 0543U, 0547U, 0549U, 0555U, 0561U, 0562U, 0565U, 0566U, 0567U, 0569U, 0571U
Individual gene and targeted analyses (examples require prior authorization): CYP2D6 targeted sequence analyses (0073U, 0074U, 0075U, 0072U), COMT gene analysis (0032U), red blood cell antigen (fetal RhD) PCR and cfDNA assays (0536U, 0494U), BRCA1/BRCA2 full sequence and duplication/deletion analyses (81161, 81162, 81164), CFTR full sequence and variant-specific testing (81223, 81224, 81222, 81221), TP53 full gene sequence (81351), SMN1/SMN2 full gene analysis (0236U), and other single-gene analyses listed below (selected examples shown elsewhere in this section).
Genomic panels and exome/genome testing that require prior authorization (examples): multi-gene genomic sequence panels and panels for hereditary conditions and cancer predisposition (CPT/Medicare codes 81411–81419, 81425–81427, 81435, 81439–81441, 81470–81471, 81404, 81420, 81422, 81426), exome and genome sequencing and re-evaluation (81518, 81414, 81415, 81413, 81417, 81425, 81427), mitochondrial and large-panel testing (81440, 81456), and tumor/oncology-related NGS and methylation assays (e.g., 0340U, 0349U, 0340U, 0405U, 0569U, 0537U).
Molecular pathology and multianalyte algorithmic assays requiring prior authorization (examples): molecular pathology procedure levels and multianalyte algorithmic assays (CPT/Medicare codes 81407, 81408, 81441, 81442, 81507, 81525, 81529, 81542, 81546, 81554, 81595, 81599, 0045U, 0022U).
Pathology and cytogenomic tests requiring prior authorization (examples): cytogenomic microarray and constitutional analyses, genome-wide arrays and copy number analysis (81229, 81277, 81278, 81220, 81228), fetal aneuploidy and cell-free fetal DNA panels (81420, 81507), and related maternal-fetal genomic tests listed above.
Tests for minimal residual disease (MRD), tumor profiling, and liquid biopsy that require prior authorization (examples): MRD NGS of cell-free DNA (0306U, 0340U, 0340U, 0561U), pan-cancer and pan-tumor methylation/epigenomic assays (0332U, 0537U, 0569U), targeted ctDNA panels and tumor NGS from plasma or FFPE (0405U, 0571U, 0543U, 0499U, 0562U, 0567U).
Drug metabolism/pharmacogenomic panels and multi-gene drug metabolism testing that require prior authorization (examples): multi-gene pharmacogenomic reports (0347U, 0348U, 0350U, 0349U, 0434U, 0419U).
Durable medical equipment (DME), prosthetics, orthotics, power wheelchairs, accessories and supplies requiring prior authorization (examples): numerous E- and L- codes and K-codes listed including but not limited to E0194, E0171, E0170, E0615, E0760, E0856, E0968, E0978, E0995, E1004, E1200, E1239, E1296, E1801, E2363–E2378, E2381–E2398, E2500–E2631, L3250, L5649, L5679, L7180, K0820, K0850, K0860–K0869, K0885, K0890–K0899, L0468
Wheelchair accessories and components (examples): accessories, batteries, chargers, cushions, power seating systems, head/chin controls, drive motors, caster forks, tires, and other replacement components (E2211, E2212, E2213, E2214, E2216, E2221, E2226, E2291–E2366, E2382–E2398, E2602–E2631, E2611–E2629).
Neurostimulation and implantable devices, leads and related procedures requiring prior authorization (examples): neurostimulator implantation and related electrode array procedures, sacral nerve stimulation, peripheral neurostimulator generators and replacements (64555, 64561, 64575, 64597, 64640, 32853, 33935, 50360).
Radiation therapy procedures and brachytherapy that require prior authorization (examples): proton and brachytherapy delivery and planning codes, complex dosimetry and remote afterloading HDR services (77316, 77318, 77522, 77523, 77525, 77770–77772, 77334, 77402, 77412).
High-cost drugs, biologics, gene therapies, and injections requiring prior authorization (examples): pegylated and specialty injections and gene therapies (J0219, J0225, J1323, J2507, J2778, J2941, J2998, J3380, J3385, J3393–J3399, J7172, J7175, J7180–J7202, J7207, J7209, J7322, J9034–J9036, Q4272–Q4397, Q4280, Q4282, Q4288, Q4391, Q4395, Q4397).
Surgical and complex procedural codes requiring prior authorization (examples): selected major surgical, transplant, spine, cranial, and complex orthopaedic procedures (41019, 50360, 55860, 55862, 55874, 55875, 57156, 61796–61799, 61800, 61889, 63302, 63306, 63655, 63053, 63200-range entries listed in source), and other high-resource procedures listed in this section.
Specialized diagnostic imaging and cardiac/vascular catheterization procedures requiring prior authorization (examples): select CT, MRI, cardiac CT, and catheterization codes (70486, 70554, 70553, 72133, 72147, 74160, 75573, 93457, 93459, 76390).
Therapeutic and rehabilitative devices and services requiring prior authorization (examples): transcutaneous electrical nerve stimulation devices and supplies, tibial nerve stimulators, gait modulation systems, oxygen equipment and accessories, apnea monitors, breast pumps, hydrocollator units, and related codes (L1685, 0469U, 0498U, E0619, E0604, E0618, E0329, E0239, E0225, E0175, E0350, E0352).
Psychological and neuropsychological testing services requiring prior authorization when billed with extended-duration or additional testing codes (examples): 96131, 96132, 96137, 96139, 96113, 96137, 96132 and related add-on time-based test administration codes.
All other codes and items explicitly listed in the payer's prior authorization list: this section includes many additional CPT/HCPCS/Medicare codes and unlisted procedure codes (e.g., 84999, 17999, 55899, J3590, 97139, 0930T, 0931T, 0910T, 0815T, 0620T, 0589U and other entries shown in the consolidated list above) — providers must obtain prior authorization prior to providing services associated with codes appearing in this policy.