Medicare Advantage Medical Policy Updates

New Medical Policies

Medical Policy: M.44 Genetic Testing

Effective Date: 05/01/2026
Preauthorization Required: Yes

Currently genetic testing codes are in policy M.15. We are creating a new policy just for genetic testing and additional codes will be added to this policy.  All Genetic Testing codes will be under this policy. 

New codes that will be included in this policy:
81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81161, 81162, 81175, 81176, 81191, 81192, 81193, 81194, 81195, 81209, 81218, 81221, 81222, 81223, 81224, 81230, 81231, 81246, 81248, 81249, 81251, 81252, 81253, 81258, 81259, 81262, 81263, 82164, 81265, 81266,  81267, 81268,  81269, 81278, 81279, 81339, 81341, 81346, 81347, 81348, 81439, 81351, 81352, 81353, 81357, 81360, 81361, 81362, 81362  81364, 81371, 81373, 81378, 81419, 81425, 81426, 81427, 81430, 81431, 81434, 81440, 81441,  81448,  81456, 81462, 81463, 81464, 81470, 81471, 81490, 81493, 81500, 81504, 81506, 81517, 81520, 81521, 81523, 81535, 81536, 81545, 81551,,81554, 81560, 81595,  
0001U 0002M 0002U 0003M 0004M 0005U 0006M 0007M 0011M 0012M 0012U 0013M 0014M 0015M 0016M 0016U 0017M "0017U 0018U 0019M 0019U 0020M 0021U 0022U 0023U 0027U 0028U 0031U 0032U 0033U 0035U 0037U 0040U 0046U 0048U 0049U 0078U 0079U 0081U 0083U 0084U 0087U 0087U 0088U 0091U 0092U 0093U 0094U 0095U 0101U 0104U 0105U 0108U 0111U 0113U 0114U 0119U 0120U 0124U 0125U 0129U 0130U 0131U 0132U 0133U 0134U 0135U 0136U 0137U 0138U 0153U 0154U 0155U 0156U 0157U 0158U 0159U 0160U 0161U 0162U 0163U 0168U 0169U 0170U 0171U 0172U 0173U 0174U 0175U 0177U  0180U 0181U 0182U 0183U 0184U 0185U 0186U 0187U 0188, 0189U 0190U 0191U 0192U 0193U 0194U 0195U 0196U 0197U 0198U 0199U 0200U 0201U 0203U 0204U 0205U 0206U 0206U 0207U 0208U 0209U 0211U 0212U 0213U 0214U 0215U 0216U 0217U 0218U 0220U 0221U 0222U 0228U 0228U 0229U 0230U 0230U 0231U 0232U 0232U 0233U 0234U 0235U 0236U 0237U 0238U 0239U 0242U 0243U 0246U 0248U  0248U 0249U 0249U 0250U 0252U 0253U 0254U 0255U  0256U 0257U 0258U 0260U 0261U 0262U 0263U 0264U 0265U 0266U 0267U 0268U 0269U 0270U 0271U 0272U 0273U 0274U 0276U 0277U 0278U 0279U 0280U 0281U 0283U 0284U 0285U 0287U 0289U 0290U 0291U 0292U 0293U 0294U 0295U 0296U 0297U "0298U 0299U 0300U 0306U, 0307U 0308U 0309U 0310U 0312U 0313U 0315U 0317U 0318U 0319U 0320U 0322U 0324U 0325U 0331U 0332U 0333U 0335U 0336U 0337U 0338U 0340U 0341U 0342U 0343U 0347U 0348U 0349U 0350U 0355U 0356U 0357U 0359U 0360U 0362U 0363U 0364U 0365U 0366U 0367U 0368U 0375U 0376U 0378U 0385U 0386U 0387U 0388U 0392U 0395U 0396U 0397U 0398U 0400U 0401U 0403U 0404U 0405U 0406U 0410U 0413U 0414U 0415U 0417U 0418U 0420U 0421U 0422U 0423U 0424U 0425U 0426U 0434U 0435U 0436U 0437U 0438U 0439U 0440U 0444U 0448U 0449U 0450U 0451U 0458U 0468U 0541U 0542U 0545U 0546U 0547U 0548U 0551U 0599U

Medical Policy: M.46 Transcranial Magnetic Stimulation (TMS)

Effective Date: 05/01/2026
Preauthorization Required: Yes 
Policy Statement

Using  LCD Transcranial Magnetic Stimulation (TMS) (L34641)
Approving one treatment for 5 days for 4-6 weeks 

Codes: 90867, 90868, 90869

Medical Policy: M.47 Home Mechanical Ventilator

Effective Date: 05/01/2026
Preauthorization Required: Yes 
Policy Statement

Using NCD Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure (CRF) Consequent to Chronic Obstructive Pulmonary Disease (COPD) (240.9)
Codes: E0465, E0466, E0467, E0468

Medical Policy: M.48 Intranasal Cryoablation or Radiofrequency Ablation for Rhinitis

Effective Date: 05/01/2026
Preauthorization Required: Yes 
Policy Statement 

1. Cryoablation (e.g., ClariFix) or radiofrequency (e.g., RhinAer) ablation for allergic and non-allergic rhinitis is considered not reasonable and necessary  because its effectiveness has not been established.

Codes: 31242 31243 30999 C9771

Medical Policy: M.49 Sphenopalatine ganglion blocks

Effective Date: 05/01/2026
Preauthorization Required: Yes 
Policy Statement 

1. Sphenopalatine ganglion blocks are considered not reasonable and necessary for ALL Indications because its effectiveness has not been established

Codes: 64505 64999

Medical Policy: M.50 Intraosseous Radiofrequency Ablation of the Basivertebral for Chronic Low Back Pain

Effective Date: 05/01/2026
Preauthorization Required: Yes  
Policy Statement  

1. Intraosseous radiofrequency ablation of the basivertebral nerve (L3 through S1 vertebrae) may be considered reasonable and necessary when all the following are met:
   1. Skeletally mature patients (age >18 years old), AND
   2. Chronic low back pain for at least 6 months, AND
   3. Conservative measures tried and failed:
      1. At least 6 weeks of documented physical therapy AND
      2. At least 6 months of pharmacotherapy (narcotics, non-narcotic analgesics, muscle relaxants, neuroleptics, and/or anti-inflammatories) AND
   4. MRI demonstrates Type 1 or Type 2 Modic changes at one or more vertebrae from L3 to S1, AND
   5. Activities of daily living limited due to persistent low back pain
2. All other uses of intraosseous radiofrequency ablation are considered not reasonable and necessary because its effectiveness has not been established for other indications or criteria.

Codes: 64628, 64629, 22899

Medical Policy: M.51 Intravascular Shockwave Lithotripsy

Effective Date: 05/01/2026
Preauthorization Required: Yes 
Policy Statement 

1. Intravascular Shockwave Lithotripsy is considered not reasonable and necessary for all indications as the effectiveness of this procedure has not been established.

Codes: 92972 C1761 C9764 C9765 C9766 C9767 C9772 C9773 C9774 C9775

Medical Policy: M.52 Cardiac Hemodynamic Monitoring in the Management of Heart Failure in the Outpatient Setting

Effective Date: 05/01/2026
Preauthorization Required: Yes 
Policy Statement

1. Cardiac hemodynamic monitoring for the management of heart failure when performed in an ambulatory or outpatient setting, using implantable direct pressure monitoring of the pulmonary artery, thoracic bioimpedance, inert gas rebreathing, and arterial pressure during the Valsalva maneuver is considered not reasonable and necessary as the effectiveness and safety to the patient of this procedure has not been established.

Codes: 33289 93264 93701 C2624 G0555

Medical Policy: M.53 Aqueous Shunts and Stents for Glaucoma

Effective Date: 05/01/2026
Preauthorization Required: Yes 
Policy Statement

1. Insertion of ab externo aqueous shunts approved by the U.S. Food and Drug Administration may be considered reasonable and necessary  as a method to reduce intraocular pressure in individuals with glaucoma where medical therapy has failed to adequately control intraocular pressure.
2. Use of an ab externo aqueous shunt for all other conditions, including individuals with glaucoma when intraocular pressure is adequately controlled by medications, is considered not reasonable and necessary because the effectiveness of this procedure has not been established. 
3. Insertion of ab interno aqueous stents approved by the U.S. Food and Drug Administration as a method to reduce intraocular pressure in individuals with glaucoma where medical therapy has failed to adequately control intraocular pressure may be considered reasonable and necessary.
4. Implantation of 1 or 2 U.S. Food and Drug Administration-approved ab interno stents in conjunction with cataract surgery may be considered reasonable and necessary in individuals with mild-to-moderate open-angle glaucoma treated with ocular hypotensive medication.
5. Use of ab interno stents for all other conditions is considered not reasonable and necessary because the effectiveness of this procedure has not been established

Codes: 66179 66180 66183 66184 66185 0253T 0449T 0450T 0474T  0671T C1783 L8612

PCS 089230Z  089330Z

Medical Policy: M.54 Balloon Eustachian Tuboplasty

Effective Date: 05/01/2026
Preauthorization Required: Yes 
Policy Statement

1. Balloon eustachian tuboplasty may be considered reasonable and necessary when ALL the following criteria are met:
   1. A diagnosis of eustachian tube dysfunction (ETD), confirmed by at least two of the following:
      1. abnormal tympanometry findings including negative middle ear pressure AND
      2. retracted tympanic membrane on otoscopic exam AND
      3. symptoms of ETD meeting an ETDQ-7 score of at least 2, for at least 12 weeks AND
      4. inability to perform Valsalva maneuver
         AND
   2. The patient has tried and failed at least two of the following therapies:
      1. systemic antihistamines or decongestants for at least 4 weeks
      2. nasal topical decongestants with continuous daily use for at least 4 weeks
      3. nasal steroid spray for at least 4 weeks or completed a course of oral steroids within the previous 90 days
      4. interventional treatment with myringotomy or tympanostomy tubes
2. Balloon eustachian tuboplasty for all other indications is considered not reasonable and necessary because the effectiveness has not been established.

Codes: 69705 69706 69799 C9745

Medical Policy: M.55 Radiofrequency Ablation or Transarterial Therapy for the Liver

Effective Date: 05/01/2026
Preauthorization Required: Yes 
Policy Statement

Using InterQual Criteria

Cryoablation, Liver
Microwave Ablation, Liver
Percutaneous Ethanol Injection (PEI), Liver
Radiofrequency Ablation (RFA), Liver
Transarterial Bland Embolization (TAE), Liver
Transarterial Chemoembolization (TACE), Liver
Transarterial Radioembolization (TARE or RE), Liver

Codes: 37242 37243 47370 47380 47382 47383 76940

Medical Policy: M.56 Lower Esophageal Myotomy for Treatment of Achalasia and Gastroparesis

Effective Date: 05/01/2026
Preauthorization Required: Yes 
Policy Statement

1. Peroral endoscopic myotomy (POEM) may be considered reasonable and necessary when ALL the following criteria are met:
   1. The individual is 18 years of age or older; AND
   2. The individual has a diagnosis of spastic achalasia type III; AND
   3. Echardt symptom score is greater than three (3) (see guidelines).
2. Peroral endoscopic myotomy (POEM) is considered not reasonable and necessary if the above criteria are not met and for all other                
   indications.
3. Gastric peroral endoscopic myotomy (G-POEM) is considered not reasonable and necessary  as a treatment for gastroparesis and all other indications because the effectiveness has not been established.

Codes: 43497, 43499, 43999

Medical Policy: Outpatient Urine Drug Testing for Pain Management and Substance Use Disorder

Effective Date: 05/01/2026
Preauthorization Required: No
Policy Statement

1. Definitive UDT may be considered reasonable and necessary as part of outpatient pain management or substance use disorder treatment only for the following:
   1. Presumptive testing is not commercially available for one or more drugs of clinical relevance to the patient's treatment, OR
   2. Presumptive testing has produced an unexpected positive result, which is inadequately explained by the patient, and the results of definitive testing will affect clinical care: OR
   3. Presumptive testing has produced an unexpected negative test, with provider concerns for medication diversion; OR
   4. There is a need for definitive levels to compare with established benchmarks, necessary for clinical decision-making.
2. All other uses of UDT in the outpatient setting are considered not reasonable and necessary because the effectiveness has not been established; including but not limited to:
   • Routine UDT, such as testing at every visit, that is not based on the patient's specific risk factors and treatment program.
   • Use of definitive testing when presumptive testing would be adequate for clinical decision-making.
3. Use of oral fluid drug testing and hair drug testing for both presumptive (qualitative) testing and definitive (quantitative) testing are considered not reasonable and necessary because the effectiveness has not been established.   

Codes: G0480 G0481 G0482 G0483