Procedure
Code

Procedure Code Description

Prior
Authorization
Rule

0631U

Oncology (solid tumor), DNA, sequence analysis of 15 genes including BRCA1 and BRCA2 for identification of clonal hematopoiesis, blood, reported as tumor-derived or nontumor-derived

Yes

0632U

Red blood cell antigen (fetal RhD gene analysis), multiplex polymerase chain reaction (PCR) and next-generation sequencing (NGS) of circulating cell-free DNA (cfDNA), plasma from pregnant individuals known to be RhD negative, reported as detected or not d

Yes

0633U

Obstetrics (single-gene noninvasive prenatal test), cell-free DNA (cfDNA), next-generation sequencing (NGS) analysis of 1 or more targets (eg, CFTR, SMN1, HBB, HBA1, HBA2) to identify paternally inherited pathogenic variants and to determine fetal inherit

Yes

0634U

Oncology (breast cancer), cell-free DNA (cfDNA), evaluation of 11 ESR1 variants (E380Q, S463P, L536R, Y537C, Y537N, Y537S, D538G, V422del, L536H, L536P, Y537D) using droplet digital PCR (ddPCR), plasma, reported as positive or negative

Yes

0635U

Autoimmune (atopic dermatitis), mRNA, next-generation sequencing (NGS), gene expression profiling of 487 genes, noninvasive skin-surface scraping, algorithm reported as likelihood of response to therapy

Yes

0636U

Babesia (Babesiosis), antibody detection of 20 recombinant protein groups, by immunoassay, IgG

Yes

0637U

Babesia (Babesiosis), antibody detection of 20 recombinant protein groups, by immunoassay, IgM

Yes

0638U

Bartonella (Bartonellosis), antibody detection of 32 recombinant protein groups, by immunoassay, IgG

Yes

0639U

Bartonella (Bartonellosis), antibody detection of 32 recombinant protein groups, by immunoassay, IgM

Yes

0640U

Oncology (leptomeningeal metastases), tumor cell selection, identification, detection and enumeration based on differential CD318(CDCP1), SUSD2, CD340(erbB2/HER2), HGFR/cMET, FOLR1, EGFR, N cadherin, MUC1, EpCAM, and TROP2 antibody biomarkers, cerebrospin

Yes

0641U

Oncology (minimal residual disease [MRD]), tumor DNA, next-generation sequencing (NGS), using formalin-fixed paraffin-embedded (FFPE) tissue and blood samples, initial (baseline) assessment

Yes

0642U

Oncology (minimal residual disease [MRD]), tumor DNA, next-generation sequencing (NGS), whole blood, comparison to previously performed analyses, reported as trend in circulating tumor DNA (ctDNA) level

Yes

0643U

Oncology (genitourinary cancer), cell-free circulating tumor DNA (ctDNA), 200 genes, next-generation sequencing (NGS), interrogation for single-nucleotide variants (SNVs), insertions/deletions, gene rearrangements, copy number alterations, and tumor mutat

Yes

0644U

Oncology (leukemia), minimal residual disease (MRD) detection for rearrangements, blood or bone marrow, personalized assay design and baseline quantification

Yes

0645U

Oncology (leukemia), minimal residual disease (MRD) detection for rearrangements, based on digital PCR, blood or bone marrow, reported as not detected or detected with estimated abundance

Yes

0646U

Oncology (molecular residual disease), whole genome sequence analysis, cell-free DNA, whole blood, and formalin-fixed paraffin-embedded (FFPE) tumor tissue DNA, baseline assessment

Yes

0647U

Oncology (molecular residual disease), whole genome sequence analysis, cell-free DNA (cfDNA), whole blood, assessment utilizing patient-specific tumor information, reported as negative or percent circulating tumor DNA (ctDNA)

Yes

0648U

Oncology (solid tumor), targeted genomic sequencing analysis, to detect deletions, insertions, and substitutions in 42 genes, copy number amplifications in 10 genes, and fusions and splice variants in 18 driver genes from DNA and RNA extracted from formal

Yes

0649U

Neurology (Alzheimer disease), DNA, targeted next-generation sequencing (NGS) of AD-1 and AD-2 target regions, whole blood, prognostic algorithmic analysis, reported as categorization of cognitive status

Yes

0650U

Drug metabolism (adverse drug reactions and drug response), genotyping of 9 genes (ie, CYP2D6, CYP2C19, G6PD, SLCO1B1, HLA-B*58:01, NAT2, CYP2C9, VKORC1, ABCG2), reported as metabolizer status and transporter function

Yes

0651U

Oncology (hereditary cancer), genomic DNA, 55 hereditary cancer pre-dispositioned genes, next-generation sequencing (NGS) and digital multiplex ligation-dependent probe amplification for variants, small indels (<40 base pairs), using saliva, whole blood o

Yes

0652U

Drug metabolism (adverse drug reactions), DNA analysis of 13 genes by targeted genotyping, using saliva or buccal swab, reported as diplotype and metabolizer status

Yes

0653U

Nephrology (inherited kidney disorders), DNA, analysis of approximately 700 genes associated with inherited kidney diseases by exome sequencing, using whole blood, saliva, or nail clipping, reported as an interpretive clinical report classifying pathogeni

Yes

0654U

Inborn error of metabolism (primary mitochondrial disease), mitochondrial analysis of 1 enzyme complex by western blot analysis, using cultured skin fibroblasts, diagnostic qualitative result

Yes

0655U

Inborn error of metabolism (primary mitochondrial disease), mitochondrial analysis of 1 enzyme complex by spectrophotometric kinetic assay, using cultured skin fibroblasts, diagnostic quantitative result

Yes

0656U

Inborn error of metabolism (primary mitochondrial disease), mitochondrial analysis of 1 enzyme complex by radioactive activity assay, using cultured skin fibroblasts, diagnostic quantitative result

Yes

0657U

Rare diseases (constitutional/heritable disorders), rapid whole genome sequence analysis of comparator nuclear and mitochondrial DNA by next-generation sequencing (NGS), using blood or buccal sample, relevant variants reported with proband results

Yes

0658U

Rare diseases (constitutional/heritable disorders), rapid whole genome sequence analysis of nuclear and mitochondrial DNA by next-generation sequencing (NGS) for single-nucleotide variants (SNVs), insertions/deletions, copy number variants, uniparental di

Yes

0659U

Rare diseases (constitutional/heritable disorders), ultrarapid whole genome sequence analysis of nuclear and mitochondrial DNA by next-generation sequencing (NGS) for single-nucleotide variants (SNVs), insertions/deletions, copy number variants, uniparent

Yes

1026T

Transvaginal laser photobiomodulation therapy of pelvis, provided by a physician or other qualified health care professional

Yes

1027T

Percutaneous insertion or replacement of neurostimulation catheter via left subclavian or left jugular vein into the superior vena cava, with verification of capture of phrenic nerves, mapping and programming, and delivery of transvenous phrenic neurostim

Yes

1028T

Mapping and programming of neurostimulation catheter with delivery of transvenous phrenic neurostimulation therapy in ventilated patients, with repositioning and verification of left phrenic nerve capture, per session

No

1029T

Mapping and programming of neurostimulation catheter with delivery of transvenous phrenic neurostimulation therapy in ventilated patients, without catheter repositioning, per session

No

1030T

Creation of digital 3D model from surface mesh files of patient-specific anatomy (eg, final anatomic representation [FAR]), cumulative time for up to 30 days; initial 30 minutes

Yes

1031T

Creation of digital 3D model from surface mesh files of patient-specific anatomy (eg, final anatomic representation [FAR]), cumulative time for up to 30 days; each additional 30 minutes (List separately in addition to code for primary procedure)

No

1032T

Creation of digital 3D model from surface mesh files of patient-specific anatomy (eg, final anatomic representation [FAR]) and digital simulation, cumulative time for up to 30 days; initial 60 minutes

Yes

1033T

Creation of digital 3D model from surface mesh files of patient-specific anatomy (eg, final anatomic representation [FAR]) and digital simulation, cumulative time for up to 30 days; each additional 30 minutes (List separately in addition to code for prima

No

1034T

Creation of digital 3D model from surface mesh files of patient-specific anatomy (eg, final anatomic representation [FAR]), digital simulation, and computational analyses (eg, computational fluid dynamics, finite element analysis), cumulative time for up

Yes

1035T

Creation of digital 3D model from surface mesh files of patient-specific anatomy (eg, final anatomic representation [FAR]), digital simulation, and computational analyses (eg, computational fluid dynamics, finite element analysis), cumulative time for up

Yes

1036T

Noninvasive hemodynamic assessment with pulmonary pressures and ejection fraction when performed, including passive acquisition of acoustic and electrical signals, augmentative algorithmic analysis, and generation of a clinical report with review, interpr

No

1037T

Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant pancreatic tissue, including imaging guidance

Yes

1038T

Autologous muscle cell therapy, injection(s) of muscle progenitor cells into the tongue, including esophagoscopy, when performed

Yes

1039T

Connectomic analysis of previously performed multi-modal brain magnetic resonance imaging (MRI) requiring physician or other qualified health care professional (QHP) analysis of software- and physician-generated structural and functional maps for integrat

Yes

1040T

Bronchoscopy, flexible, with bronchial cryotherapy, 1 lung, including trachea, when performed

No

1041T

Augmentative algorithmic analysis of encephalographic waveforms to identify the source and propagation of epileptiform activity, including artifact reduction with analysis of 3D localization of spike sources throughout the examination, 3D animations over

Yes

1042T

Implantation of absorbable urologic scaffold for prostatic urethra restoration of reconstructed bladder neck and urethral anastomosis (List separately in addition to code for primary procedure)

No

1043T

Quantitative magnetic resonance, without imaging, for analysis of liver tissue, including assessment of 1 or more parameters (eg, proton density fat fraction [PDFF], water diffusion, T1-water relaxation time), with automatically generated report

Yes

1044T

Harvest of full-thickness skin for autologous heterogeneous skin-construct graft, including direct closure of donor site; first 5 sq cm or less

No

1045T

Harvest of full-thickness skin for autologous heterogeneous skin-construct graft, including direct closure of donor site; each additional 5 sq cm, or part thereof (List separately in addition to code for primary procedure)

No

1046T

Autologous heterogeneous skin-construct graft application, trunk, arms, legs; first 50 sq cm or less, or 0.5% of body area of infants and children

Yes

1047T

Autologous heterogeneous skin-construct graft application, trunk, arms, legs; each additional 50 sq cm, or each additional 0.5% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)

No

1048T

Autologous heterogeneous skin-construct graft application, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 50 sq cm or less, or 0.5% of body area of infants and children

Yes

1049T

Autologous heterogeneous skin-construct graft application, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 50 sq cm, or each additional 0.5% of body area of infants and children, or part the

No

1050T

Insertion, subcutaneous heart failure decompensation monitor, containing sensors that measure, at a minimum, heart rate, impedance, respiration rate, physical activity, heart sounds

Yes

1051T

Removal of subcutaneous heart failure decompensation monitor

No

1052T

Interrogation device evaluation(s), (in person or remote) up to 30 days, insertable subcutaneous heart failure decompensation monitor, analysis of physiologic parameters, including, at a minimum, heart rate, impedance, respiration rate, physical activity,

No

1053T

Programming device evaluation (in person or remote) of subcutaneous heart failure decompensation monitor, with analysis of physiologic parameters, including, at a minimum, heart rate, impedance, respiration rate, physical activity, heart sounds, with gene

No

87638

Effective

5/15/2026

Infectious agent detection by nucleic acid (DNA or RNA); rubeola (measles) virus

No

90616

Influenza virus vaccine, trivalent (tIRV), mRNA, 37.5 mcg/0.38 mL dosage, for intramuscular use

No

90639

Influenza virus vaccine, quadrivalent (qIRV), mRNA; 50 mcg/0.5 mL dosage, for intramuscular use

No

A9574

Injection, ferumoxytol, 1 mg

No

C1609

Vertebral device, motion-preserving, with screw fixation

No

C8014

Cystourethroscopy, with ureteroscopy and/or pyeloscopy, with lithotripsy, including use of a suction enabled ureteral access sheath, with irrigation (if performed)

No

C9310

Injection, leucovorin calcium (Avyxa), 1 mg

Yes

G0574

Management of new patient with dementia residing in an eligible residential care community, for use only in a Medicare-approved CMMI model (services must be furnished within a patient's eligible residential care community, including assisted living facili

No

G0575

Management of established patient with dementia residing in an eligible residential care community, for use only in a Medicare-approved CMMI model (services must be furnished within a patient's eligible residential care community, including assisted livin

No

G0669

Outcome-Aligned Payment (OAP) for technology-enabled chronic care management of early cardio-kidney-metabolic (ECKM) conditions (hypertension, or two or more of: dyslipidemia, obesity/overweight with central obesity marker, prediabetes); initial 12-month

No

G0670

Outcome-Aligned Payment (OAP) for technology-enabled chronic care management of early cardio-kidney-metabolic (ECKM) conditions (hypertension, or two or more of: dyslipidemia, obesity/overweight with central obesity marker, prediabetes); follow-on 12-mont

No

G0671

Outcome-Aligned Payment (OAP) for technology-enabled chronic care management of cardio-kidney-metabolic (CKM) conditions (one or more of: diabetes mellitus, chronic kidney disease stage 3a or 3b, atherosclerotic cardiovascular disease); initial 12-month p

No

G0672

Outcome-Aligned Payment (OAP) for technology-enabled chronic care management of cardio-kidney-metabolic (CKM) conditions (one or more of: diabetes mellitus, chronic kidney disease stage 3a or 3b, atherosclerotic cardiovascular disease); follow-on 12-month

No

G0673

Outcome-Aligned Payment (OAP) for technology-enabled chronic care management of musculoskeletal (MSK) conditions (chronic musculoskeletal pain); initial 12-month treatment period, per month

No

G0674

Outcome-Aligned Payment (OAP) for technology-enabled chronic care management of behavioral health (BH) conditions (one or more of: depression, anxiety); initial 12-month period, per month

No

G0675

Outcome-Aligned Payment (OAP) for technology-enabled chronic care management of behavioral health (BH) conditions (one or more of: depression, anxiety); follow-on 12-month period, per month

No

G0676

Standard comanagement service payment for documented review of clinical updates from ACCESS participant managing cardio-kidney-metabolic conditions (early cardio-kidney-metabolic [ECKM] or cardio-kidney-metabolic [CKM] track), per review

No

G0677

Standard comanagement service payment for documented review of clinical updates from ACCESS participant managing musculoskeletal (MSK) conditions, per review

No

G0678

Standard co-management service payment for documented review of clinical updates from ACCESS participant managing behavioral health (BH) conditions (depression, anxiety), per review

No

J0528

Injection, fosfomycin disodium, 20 mg

Yes

J1289

Injection, narsoplimab-wuug, 1 mg

Yes

J1577

Injection, immune globulin (Qivigy), 100 mg

Yes

J2361

Injection, depemokimab-ulaa, 1 mg

Yes

J2374

Apraclonidine HCl ophthalmic, 1% solution, 0.1 ml

Yes

J2789

Riboflavin 5'-phosphate, ophthalmic solution (Epioxa HD/Epioxa), up to 2 ml

Yes

J3386

Injection, etuvetidigene autotemcel, per treatment

Yes- carve out

J3405

Injection, onasemnogene abeparvovec-brve, per treatment

Yes- carve out

J7176

Injection, human fibrinogen-chmt (Fesilty), 1 mg

Yes

J9053

Injection, belantamab mafodotin-blmf, 0.1 mg

Yes

J9062

Injection, amivantamab 5 mg and hyaluronidase-lpuj

Yes

J9232

Injection, docetaxel (Hospira), not therapeutically equivalent to J9171, 1 mg

Yes

M0231

Intravenous infusion, tocilizumab-bavi, for hospitalized adult patients with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, noninvasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO)

Yes

M0232

Intravenous infusion, tocilizumab-bavi, for hospitalized adult patients with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, noninvasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO)

Yes

Q0234

Injection, tocilizumab-bavi, for hospitalized adult patients with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, noninvasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg

Yes

Q5164

Injection, ustekinumab-hmny (Starjemza), biosimilar, 1 mg

Yes

Q5165

Injection, denosumab-mobz (Oziltus), biosimilar, 1 mg

Yes

Q5166

Injection, denosumab-desu (Osvyrti/Jubereq), biosimilar, 1 mg

Yes

Q5167

Injection, denosumab-qbde (Enoby/Xtrenbo), biosimilar, 1 mg

Yes

Q5168

Injection, ranibizumab-leyk (Nufymco), biosimilar, 0.1 mg

Yes

Q5169

Injection, pegfilgrastim-unne (Armlupeg), biosimilar, 0.5 mg

Yes

Q5170

Injection, aflibercept-boav (Eydenzelt), biosimilar, 1 mg

Yes

Q5171

Injection, denosumab-mobz (Boncresa), biosimilar, 1 mg

Yes