CurrentMass General Brigham Health PlanPolicy N/A

CPT/HCPCS code coverage determinations (experimental/investigational, prior authorization, PA exceptions, redirect to pharmacy)

Lists specific procedure and supply codes that are not covered, require prior authorization, do not require prior authorization, or are redirected to pharmacy for Mass General Brigham Health Plan commercial, ASO, and MGB ACO lines of business.

Policy Summary

PayerMass General Brigham Health Plan

PolicyCPT/HCPCS code coverage determinations (experimental/investigational, prior authorization, PA exceptions, redirect to pharmacy)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionCheck the code lists to determine whether a CPT/HCPCS code is not covered, requires prior authorization, is exempt from prior authorization, or should be redirected to pharmacy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~120+listed CPT/HCPCS/Codes across categories in document

Multiplecodes marked Not covered (experimental/investigational)

Multiplecodes requiring prior authorization

Severalcodes listed as No prior authorization required

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Not covered / Experimental

The following codes are identified as not covered because they are considered experimental and investigational, or are not payable for specific plan lines.

Not covered / Experimental codes (Commercial/ASO and MGB ACO where noted):

ANY of the following

A9506 = Graphite crucible for preparation of technetium tc 99m-labeled carbon aerosol, one crucible.
C1605 = Pacemaker; leadless, dual chamber (right atrial and right ventricular implantable components), rate-responsive, including all necessary components for implantation.
C1606 = Adapter, single-use, for attaching ultrasound system to upper gastrointestinal endoscope.
C9901 = Endoscopic defect closure within the entire gastrointestinal tract, including system and tissue anchoring components.
Q4311, Q4312, Q4313, Q4314, Q4315, Q4316, Q4317, Q4318, Q4319, Q4320, Q4321, Q4324, Q4326 = Various biologic graft/allograft products, per square centimeter (examples: Acesso, Dermabind FM, Reeva FT, Regenelink, Amniotx, Woundplus, etc.).
0450U, 0451U, 0457U, 0458U, 0459U, 0462U, 0468U, 0472U = Selected laboratory/genomic and specialty diagnostic tests (e.g., LC-MS/MS monoclonal paraprotein analyses, PFAS panels, tear fluid assays, CSF amyloid/tau assays, melatonin profiles, NASH algorithm tests, salivary protein assays).
0867T–0899T (selected T-codes) = Multiple emerging procedures and diagnostic technologies (examples: transperineal laser ablation of BPH 0867T; high-resolution gastric electrophysiology mapping 0868T; various image-augmentative analyses, device implant/revision codes, therapeutic and diagnostic procedures 0870T–0899T).

No prior authorization required

The following codes do not require prior authorization for MGB ACO and Commercial/ASO.

No prior authorization required (examples):

ANY of the following

90684 = Pneumococcal conjugate vaccine, 21 valent (PCV21), for intramuscular use.
J0687 = Injection, cefazolin sodium, 500 mg.
J0872 = Injection, daptomycin, 1 mg (specified product).
J1598; J1597 = Injection, glycopyrrolate formulations, 0.1 mg.

Prior authorization required

The following codes require prior authorization for Commercial/ASO and/or MGB ACO; some listed codes are noted as not payable for MGB ACO.

Prior authorization required — commercial/ASO and MGB ACO distinctions:

ANY of the following

Genomic and advanced diagnostic tests (require prior authorization for Commercial/ASO; many are not payable for MGB ACO): examples include assays described in codes 0452U, 0453U, 0454U, 0456U, 0460U, 0461U, 0464U, 0465U, 0466U, 0467U, 0469U, 0470U, 0473U, 0474U, 0475U, 0471U, 0455U, 0463U.
Specialty biologic injections and cell/gene therapies (require prior authorization for MGB ACO and Commercial/ASO where indicated): J7171 = Injection, adamts13, recombinant-krhn, 10 iu; J3247 = Injection, secukinumab, intravenous, 1 mg; J3263 = Injection, toripalimab-tpzi, 1 mg; J3394 = Injection, lovotibeglogene autotemcel, per treatment; J3393 = Injection, betibeglogene autotemcel, per treatment.
Commercial/ASO prior authorization example: J2267 = Injection, mirikizumab-mrkz, 1 mg (prior authorization required for Commercial/ASO).

Pharmacy redirection

The following products are redirected to the Pharmacy channel for MGB ACO, Commercial and ASO.

Pharmacy redirection — products redirected to Pharmacy channel:

ANY of the following

J8611 = Methotrexate (Jylamvo), oral, 2.5 mg.
J8612 = Methotrexate (Xatmep), oral, 2.5 mg.
J1748 = Injection, infliximab-dyyb (Zymfentra), 10 mg.
J7355 = Injection, travoprost, intracameral implant, 1 mcg.

Code listings and statuses

Not covered / Experimental HCPCS/CPT/OthermixedNot Covered

A9506	Graphite crucible for preparation of technetium tc 99m-labeled carbon aerosol, one crucible
C1605	Pacemaker; leadless, dual chamber (right atrial and right ventricular implantable components), rate-responsive, including all necessary components for implantation
C1606	Adapter, single-use, for attaching ultrasound system to upper gastrointestinal endoscope
C9901	Endoscopic defect closure within the entire gastrointestinal tract, including all system and tissue anchoring components
Q4311	Acesso, per square centimeter
Q4312	Acesso per square centimeter ac
Q4313	Dermabind fm, per square centimeter
Q4314	Reeva ft, per square centimeter
Q4315	Regenelink amniotic membrane allograft, per square centimeter
Q4316	Amchoplast, per square centimeter

1–10 of 58

1/6

No prior authorization required — Covered Codes (MGB ACO and Commercial/ASO)mixedCovered

90684	Pneumococcal conjugate vaccine, 21 valent (PCV21), for intramuscular use
J0687	Injection, cefazolin sodium, 500 mg
J0872	Injection, daptomycin (xellia), unrefrigerated, 1 mg
J1598	Injection, glycopyrrolate (fresenius kabi), 0.1 mg
J1597	Injection, glycopyrrolate (glyrx-pf), 0.1 mg
J2183	Injection, meropenem
J2246	Injection, micafungin in sodium (baxter), 1 mg
J0211	Injection, sodium nitrite 3 mg and sodium thiosulfate 125 mg (nithiodote)
J2468	Injection, palonosetron hydrochloride (avyxa), 25 micrograms
J2470	Injection, pantoprazole sodium, 40 mg

1–10 of 13

1/2

Prior authorization required — Covered subject to PA (MGB ACO and Commercial/ASO)mixed

J7171	Injection, ADAMTS13, recombinant-krhn, 10 IU
J3247	Injection, secukinumab, intravenous, 1 mg
J3263	Injection, toripalimab-tpzi, 1 mg
J3394	Injection, lovotibeglogene autotemcel, per treatment
J3393	Injection, betibeglogene autotemcel, per treatment
J2267	Injection, mirikizumab-mrkz, 1 mg (Commercial/ASO prior authorization required)

Actions, requirements, and routing for providers

Prior Authorization

Prior Authorization Required

Prior Authorization Required. Certain medical and diagnostic services require prior authorization for Commercial and ASO lines of business and/or MGB ACO as indicated below. Providers must obtain authorization before scheduling or performing services to avoid claim denials. When prior authorization is required for Commercial/ASO but not payable for MGB ACO, do not submit for MGB ACO; for items requiring prior authorization for MGB ACO and Commercial/ASO, obtain approval for all applicable lines.

Prior authorization required for Commercial/ASO, not payable for MGB ACO: 0452U (Oncology — bladder methylated PENK DNA detection, urine), 0453U (Oncology — colorectal cfDNA methylation PCR), 0454U (Rare diseases — optical genome mapping), 0456U (Autoimmune — NGS gene expression for TNFi nonresponse), 0460U (Oncology — SNP genotyping 24 genes), 0461U (Oncology — pharmacogenomic SNP genotyping 24 genes), 0464U (Oncology — colorectal screening methylated DNA markers, stool), 0465U (Oncology — urothelial carcinoma methylation PCR), 0466U (Cardiology — CAD polygenic risk GWAS panel), 0467U (Oncology — bladder NGS urine MRD), 0469U (Rare diseases — whole genome sequence analysis, fetal), 0470U (Oncology — oropharyngeal MRD by NGS for HPV 16/18), 0473U (Oncology — 648-gene NGS tumor/normal sequencing), 0474U (Hereditary pan-cancer — 88-gene NGS panel), 0475U (Hereditary prostate cancer — 23-gene panel with MLPA/CGH), 0455U (Infectious agents — multiplex STI amplified probe technique), 0463U (Oncology — cervix mRNA expression profiling), 0471U (Oncology — KRAS/NRAS 35-variant PCR)
Prior authorization required for MGB ACO and Commercial/ASO: J7171 (Injection, ADAMTS13 recombinant), J3247 (secukinumab, IV), J3263 (toripalimab-tpzi), J3394 (lovotibeglogene autotemcel), J3393 (betibeglogene autotemcel)
Prior authorization required for Commercial/ASO: J2267 (injection, mirikizumab-mrkz, 1 mg)

Note

No Prior Authorization Required

No prior authorization is required for the listed codes for MGB ACO and Commercial/ASO. Providers may bill these services without prior authorization but must ensure documentation supports medical necessity.

90684 — Pneumococcal conjugate vaccine, 21 valent (PCV21), intramuscular
J0687 — Injection, cefazolin sodium (500 mg)
J0872 — Injection, daptomycin, 1 mg
J1598 — Injection, glycopyrrolate (fresenius kabi), 0.1 mg
J1597 — Injection, glycopyrrolate (glyrx-pf), 0.1 mg
J2183 — Injection, meropenem
J2246 — Injection, micafungin (baxter), 1 mg
J0211 — Injection, sodium nitrite and sodium thiosulfate (Nithiodote)
J2468 — Injection, palonosetron (avyxa), 25 mcg
J2470 — Injection, pantoprazole sodium, 40 mg
J2471 — Injection, pantoprazole (hikma), 40 mg
Q0224 / MO224 — Pemivibart / pemivibart IV infusion for specified pre-exposure prophylaxis (meets clinical criteria)

Billing Rule

Redirect to Pharmacy

Redirect to Pharmacy. The following products should be routed to Pharmacy benefits (Medical → Pharmacy redirection) for MGB ACO, Commercial and ASO plans. Providers should submit claims to the pharmacy benefit per payer instructions rather than as medical-administered J-codes to ensure correct billing and coverage.

J8611 — Methotrexate (Jylamvo), oral, 2.5 mg (Pharmacy)
J8612 — Methotrexate (Xatmep), oral, 2.5 mg (Pharmacy)
J1748 — Injection, infliximab-dyyb (Zymfentra), 10 mg (Pharmacy-directed)
J7355 — Injection, travoprost intracameral implant, 1 mcg (Pharmacy)
J9361 — Injection, efbemalenograstim alfa-VUXW, 0.5 mg (Pharmacy)
Q5137 — Injection, ustekinumab-auub (Wezlana) biosimilar, SC, 1 mg (Pharmacy)
Q5138 — Injection, ustekinumab-auub (Wezlana) biosimilar, IV, 1 mg (Pharmacy)
J0911 — Instillation, taurolidine and heparin catheter lock for chronic hemodialysis (Pharmacy)
J2267 — Injection, mirikizumab-mrkz, 1 mg (Pharmacy)

Key definitions and terms

Not covered (experimental/investigational) — definition & explanation

DefinitionNot covered (experimental/investigational): codes and services identified in this policy that are considered experimental or investigational, or otherwise not payable for specified plan lines (e.g., MGB ACO, Commercial/ASO).

Scope / examplesIncludes a range of CPT/HCPCS and proprietary codes (examples in policy: A9506; multiple Q43xx series products and tissue allografts; 0450U–0468U series diagnostic/novel laboratory tests).

Plan impactMarked 'Not covered' for Commercial/ASO and in several instances specifically noted as 'not payable' for MGB ACO — these codes are excluded from reimbursement under those plan lines.

RationaleClassified as experimental/investigational because the services/tests lack sufficient established evidence or are novel technologies as described in the listed entries.

Coding guidanceRefer to the policy's Not covered list for precise code-level determinations before billing; codes on this list should not be submitted for reimbursement under the affected lines of business.

Prior authorization — definition & application

DefinitionPrior authorization: an administrative requirement that certain services or drugs must receive advance approval from the plan before they will be reimbursed for Commercial/ASO and/or MGB ACO members.

When requiredThis policy lists specific CPT/HCPCS and U-codes that require prior authorization for Commercial/ASO and/or are required for MGB ACO (examples include multiple genomic/oncology tests 0452U–0460U and medically administered injections such as J7171, J3247).

Plan-specific notesSome codes are noted as 'not payable' for MGB ACO while still requiring prior authorization for Commercial/ASO — verify the code entry in the policy to determine which plan lines the PA applies to.

Provider actionObtain prior authorization from the plan before providing or billing services listed in the Prior authorization section to avoid claim denial or nonpayment.

Reference examplesPolicy examples of codes requiring PA: 0452U, 0453U, 0454U (genomic/oncology assays) and J7171, J3247, J3263, J3394 (injections / specialty products).

OpenPayer

CPT/HCPCS code coverage determinations (experimental/investigational, prior authorization, PA exceptions, redirect to pharmacy)

Coverage determinations and routing

Code listings and statuses

Actions, requirements, and routing for providers

Key definitions and terms