RegAlertRule · DFR · 22 Oct 2026
Master Precertification List - 2025 Adds and Removals
This list adds or removes prior authorization requirements for specific medical procedure and laboratory test codes, with effective and removal dates. Newly added codes include 0047U, 0211U, 0388U, 0493U, 0523U, 0529U, 0530U, 0532U–0534U, 0537U–0540U, 0543U, 0549U, 0552U–0555U, 0560U–0562U, 0565U–0569U, 0571T, 0571U, 0572U, 0575U, 0576U, 0578U, 0581U–0583U, 0585U, 0586U, 0592U, 0597U, and 0623T–0626T. Removals include codes 0071T, 0072T, 0080U, 0132U, 0261U, 0263T, 0275T, 0384U, 0385U, 0394T, 0443U, 0445U, 0449U, 0457U–0459U, 0464U, 0490U–0492U, 0544U, 0558U, 0559U, 0568U, 0574U, 0795T–0797T, 0801T–0803T, and 0823T–0824T. Precertification effective dates range from 10/1/2006 to 11/20/2025, and removal dates range from 2/28/2025 to 9/30/2026.
Master Precertification List - 2025 Adds and Removals
cigna healthcare
2025 Adds and Removals
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 0047U* | Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a risk score | 11/20/2025 | |
| 0071T | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue | 10/1/2006 | 4/25/2025 |
| 0072T | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue | 10/1/2006 | 4/25/2025 |
| 0080U | Oncology (lung), mass spectrometric analysis of galectin-3-binding protein and scavenger receptor cysteine-rich type 1 protein M130, with five clinical risk factors (age, smoking status, nodule diameter, nodule-spiculation status and nodule location), utilizing plasma, algorithm reported as a categorical probability of malignancy | 1/1/2019 | 10/17/2025 |
| 0132U* | Hereditary ovarian cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (17 genes) | 10/1/2019 | 12/31/2025 |
| 0211U* | Oncology (pan-tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded tissue, interpretative report for single nucleotide variants, copy number alterations, tumor mutational burden, and microsatellite instability, with therapy association | 5/30/2025 | |
| 0261U | Oncology (colorectal cancer), image analysis with artificial intelligence assessment of 4 histologic and immunohistochemical features (CD3 and CD8 within tumor-stroma border and tumor core), tissue, reported as immune response and recurrence-risk score | 10/1/2021 | 10/17/2025 |
| 0263T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest | 7/1/2011 | 4/25/2025 |
| 0275T* | Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar | 7/1/2011 | 12/31/2025 |
| 0384U | Nephrology (chronic kidney disease), carboxymethyllysine, methylglyoxal hydroimidazolone, and carboxyethyl lysine by liquid chromatography with tandem mass spectrometry (LC-MS/MS) and HbA1c and estimated glomerular filtration rate (GFR), with risk score reported for predictive progression to high-stage kidney disease | 4/28/2023 | 10/17/2025 |
| 0385U | Nephrology (chronic kidney disease), apolipoprotein A4 (ApoA4), CD5 antigen-like (CD5L), and insulin-like growth factor binding protein 3 (IGFBP3) by enzyme-linked immunoassay (ELISA), plasma, algorithm combining results with HDL, estimated glomerular filtration rate (GFR) and clinical data reported as a risk score for developing diabetic kidney disease | 4/28/2023 | 10/17/2025 |
| 0388U* | Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and structural variants in 37 cancer-related genes, plasma, with report for alteration detection | 5/30/2025 | |
| 0394T* | High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed | 1/1/2016 | 12/31/2025 |
| 0443U | Neurofilament light chain (NfL), ultra-sensitive immunoassay, serum or cerebrospinal fluid | 4/1/2024 | 3/28/2025 |
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 0445U | β-amyloid (Abeta42) and phospho tau (181P) (pTau181), electrochemiluminescent immunoassay (ECLIA), cerebral spinal fluid, ratio reported as positive or negative for amyloid pathology | 4/1/2024 | 10/17/2025 |
| 0449U | Carrier screening for severe inherited conditions (eg, cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies [including sickle cell disease], alpha thalassemia), regardless of race or self-identified ancestry, genomic sequence analysis panel, must include analysis of 5 genes (CFTR, SMN1, HBB, HBA1, HBA2) | 4/1/2024 | 6/27/2025 |
| 0457U | Perfluoroalkyl substances (PFAS) (eg, perfluorooctanoic acid, perfluorooctane sulfonic acid), 9 PFAS compounds by LC-MS/MS, plasma or serum, quantitative | 7/1/2024 | 3/28/2025 |
| 0458U | Oncology (breast cancer), S100A8 and S100A9, by enzyme-linked immunosorbent assay (ELISA), tear fluid with age, algorithm reported as a risk score | 9/27/2024 | 10/17/2025 |
| 0459U | β-amyloid (Abeta42) and total tau (tTau), electrochemiluminescent immunoassay (ECLIA), cerebral spinal fluid, ratio reported as positive or negative for amyloid pathology | 7/1/2024 | 10/17/2025 |
| 0464U | Oncology (colorectal) screening, quantitative real-time target and signal amplification, methylated DNA markers, including LASS4, LRRC4 and PPP2R5C, a reference marker ZDHHC1, and a protein marker (fecal hemoglobin), utilizing stool, algorithm reported as a positive or negative result | 7/1/2024 | 2/28/2025 |
| 0490U | Oncology (cutaneous or uveal melanoma), circulating tumor cell selection, morphological characterization and enumeration based on differential CD146, high molecular-weight melanoma-associated antigen, CD34 and CD45 protein biomarkers, peripheral blood | 10/1/2024 | 10/17/2025 |
| 0491U | Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytokeratins 8, 18, and 19, CD45 protein biomarkers, and quantification of estrogen receptor (ER) protein biomarker-expressing cells, peripheral blood | 10/1/2024 | 10/17/2025 |
| 0492U | Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytokeratins 8, 18, and 19, CD45 protein biomarkers, and quantification of PD-L1 protein biomarker-expressing cells, peripheral blood | 10/1/2024 | 10/17/2025 |
| 0493U | Transplantation medicine, quantification of donor-derived cell-free DNA (cfDNA) using next-generation sequencing, plasma, reported as percentage of donor-derived cell-free DNA | 7/25/2025 | |
| 0523U* | Oncology (solid tumor), DNA, qualitative, next-generation sequencing (NGS) of single-nucleotide variants (SNV) and insertion/deletions in 22 genes utilizing formalin-fixed paraffin-embedded tissue, reported as presence or absence of mutation(s), location of mutation(s), nucleotide change, and amino acid change | 1/1/2025 | |
| 0529U* | Hematology (venous thromboembolism [VTE]), genome-wide single-nucleotide polymorphism variants, including F2 and F5 gene analysis, and Leiden variant, by microarray analysis, saliva, report as risk score for VTE | 1/1/2025 | |
| 0530U* | Oncology (pan-solid tumor), ctDNA, utilizing plasma, next-generation sequencing (NGS) of 77 genes, 8 fusions, microsatellite instability, and tumor mutation burden, interpretative report for single-nucleotide variants, copy-number alterations, with therapy association | 1/1/2025 |
[*] Page 3 of 29
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 0532U* | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome and mitochondrial DNA sequencing for single- nucleotide variants, insertions/deletions, copy number variations, peripheral blood, buffy coat, saliva, buccal or tissue sample, results reported as positive or negative | 4/1/2025 | |
| 0533U* | Drug metabolism (adverse drug reactions and drug response), genotyping of 16 genes (ie, ABCG2, CYP2B6, CYP2C9, CYP2C19, CYP2C, CYP2D6, CYP3A5, CYP4F2, DPYD, G6PD, GGCX, NUDT15, SLCO1B1, TPMT, UGT1A1, VKORC1), reported as metabolizer status and transporter function | 4/1/2025 | |
| 0534U* | Oncology (prostate), microRNA, single-nucleotide polymorphisms (SNPs) analysis by RT-PCR of 32 variants, using buccal swab, algorithm reported as a risk score | 4/1/2025 | |
| 0537U* | Oncology (colorectal cancer), analysis of cell-free DNA for epigenomic patterns, next- generation sequencing, >2500 differentially methylated regions (DMRs), plasma, algorithm reported as positive or negative | 4/1/2025 | |
| 0538U* | Oncology (solid tumor), next- generation targeted sequencing analysis, formalin- fixed paraffin- embedded (FFPE) tumor tissue, DNA analysis of 600 genes, interrogation for single-nucleotide variants, insertions/deletions, gene rearrangements, and copy number alterations, microsatellite instability, tumor mutation burden, reported as actionable variant | 4/1/2025 | |
| 0539U* | Oncology (solid tumor), cell- free circulating tumor DNA (ctDNA), 152 genes, next- generation sequencing, interrogation for single- nucleotide variants, insertions/deletions, gene rearrangements, copy number alterations, and microsatellite instability, using whole-blood samples, mutations with clinical actionability reported as actionable variant | 4/1/2025 | |
| 0540U | Transplantation medicine, quantification of donor- derived cell-free DNA using next- generation sequencing analysis of plasma, reported as percentage of donor- derived cell-free DNA to determine probability of rejection | 4/1/2025 | |
| 0543U* | Oncology (solid tumor), next- generation sequencing of DNA from formalin-fixed paraffin-embedded (FFPE) tissue of 517 genes, interrogation for single- nucleotide variants, multi- nucleotide variants, insertions and deletions from DNA, fusions in 24 genes and splice variants in 1 gene from RNA, and tumor mutation burden | 4/1/2025 | |
| 0544U | Nephrology (transplant monitoring), 48 variants by digital PCR, using cell-free DNA from plasma, donor-derived cell-free DNA, percentage reported as risk for rejection | 4/1/2025 | 12/31/2025 |
| 0549U* | Oncology (urothelial), DNA, quantitative methylated real- time PCR of TRNA-Cys, SIM2, and NKX1-1, using urine, diagnostic algorithm reported as a probability index for bladder cancer and/or upper tract urothelial carcinoma (UTUC) | 4/1/2025 | |
| 0552U* | Reproductive medicine (preimplantation genetic assessment), analysis for known genetic disorders from trophectoderm biopsy, linkage analysis of disease- causing locus, and when possible, targeted mutation analysis for known familial variant, reported as low-risk or high-risk for familial genetic disorder | 7/1/2025 | |
| 0553U* | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, and a mitochondrial DNA score, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental aneuploidy, or mosaic, per embryo tested | 7/1/2025 |
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 0554U* | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from trophectoderm biopsy for aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal (euploidy), monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested | 7/1/2025 | |
| 0555U* | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested | 7/1/2025 | |
| 0558U | Oncology (colorectal), quantitative enzyme-linked immunosorbent assay (ELISA) for secreted colorectal cancer protein marker (BF7 antigen), using serum, result reported as indicative of response/no response to therapy or disease progression/regression | 7/1/2025 | 10/17/2025 |
| 0559U | Oncology (breast), quantitative enzyme-linked immunosorbent assay (ELISA) for secreted breast cancer protein marker (BF9 antigen), serum, result reported as indicative of response/no response to therapy or disease progression/regression | 7/1/2025 | 10/17/2025 |
| 0560U* | Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell-free DNA, whole blood and tumor tissue, baseline assessment for design and construction of a personalized variant panel to evaluate current MRD and for comparison to subsequent MRD assessments | 7/1/2025 | |
| 0561U* | Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell-free DNA, whole blood, subsequent assessment with comparison to initial assessment to evaluate for MRD | 7/1/2025 | |
| 0562U* | Oncology (solid tumor), targeted genomic sequence analysis, 33 genes, detection of single-nucleotide variants (SNVs), insertions and deletions, copy-number amplifications, and translocations in human genomic circulating cell-free DNA, plasma, reported as presence of actionable variants | 7/1/2025 | |
| 0565U* | Oncology (hepatocellular carcinoma), next-generation sequencing methylation pattern assay to detect 6626 epigenetic alterations, cell-free DNA, plasma, algorithm reported as cancer signal detected or not detected | 7/1/2025 | |
| 0566U* | Oncology (lung), qPCR- based analysis of 13 differentially methylated regions (CCDC181, HOXA7, LRRC8A, MARCHF11, MIR129-2, NCOR2, PANTR1, PRKCB, SLC9A3, TBR1_2, TRAP1, VWC2, ZNF781), pleural fluid, algorithm reported as a qualitative result | 7/1/2025 | |
| 0567U* | Rare diseases (constitutional/heritable disorders), whole-genome sequence analysis combination of short and long reads, for single-nucleotide variants, insertions/deletions and characterized intronic variants, copy-number variants, duplications/deletions, mobile element insertions, runs of homozygosity, aneuploidy, and inversions, mitochondrial DNA sequence and deletions, short tandem repeat genes, methylation status of selected regions, blood, saliva, amniocentesis, chorionic villus sample or tissue, identification and categorization of genetic variants | 7/1/2025 |
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 0568U | Neurology (dementia), beta amyloid (Aβ40, Aβ42, Aβ42/40 ratio), tau-protein phosphorylated at residue (eg, pTau217), neurofilament light chain (NfL), and glial fibrillary acidic protein (GFAP), by ultra-high sensitivity molecule array detection, plasma, algorithm reported as positive, intermediate, or negative for Alzheimer pathology | 7/1/2025 | 10/17/2025 |
| 0569U* | Oncology (solid tumor), next- generation sequencing analysis of tumor methylation markers (>20000 differentially methylated regions) present in cell-free circulating tumor DNA (ctDNA), whole blood, algorithm reported as presence or absence of ctDNA with tumor fraction, if appropriate | 7/1/2025 | |
| 0571T* | Insertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed | 10/17/2025 | |
| 0571U* | Oncology (solid tumor), DNA (80 genes) and RNA (10 genes), by next-generation sequencing, plasma, including single-nucleotide variants, insertions/deletions, copy-number alterations, microsatellite instability, and fusions, reported as clinically actionable variants | 7/1/2025 | |
| 0572U* | Oncology (prostate), high- throughput telomere length quantification by FISH, whole blood, diagnostic algorithm reported as risk of prostate cancer | 7/1/2025 | |
| 0574U | Mycobacterium tuberculosis, culture filtrate protein–10-kDa (CFP-10), serum or plasma, liquid chromatography mass spectrometry (LC-MS) | 7/1/2025 | 10/17/2025 |
| 0575U | Transplantation medicine (liver allograft rejection), miRNA gene expression profiling by RT-PCR of 4 genes (miR-122, miR-885, miR-23a, spike-in control), serum, plasma, or blood, algorithm reported as risk of liver allograft rejection | 10/1/2025 | |
| 0576U | Transplantation medicine (liver allograft rejection), quantitative donor-derived cell-free DNA (cfDNA) by whole genome next- generation sequencing, plasma and mRNA gene expression profiling by multiplex real-time PCR of 56 genes, whole blood, combined algorithm reported as a rejection risk score | 10/1/2025 | |
| 0578U* | Oncology (cutaneous melanoma), RNA, gene expression profiling by real- time qPCR of 10 genes (8 content and 2 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reports a binary result, either low-risk or high-risk for sentinel lymph node metastasis and recurrence | 10/1/2025 | |
| 0581U | Transplantation medicine, antibody to non-human leukocyte antigens (non-HLA), blood specimen, flow cytometry, single-antigen bead technology, 39 targets, individual positive antibodies reported | 10/1/2025 | |
| 0582U* | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome DNA sequencing for single- nucleotide variants, insertions/deletions, copy number variations, blood, saliva, tissue sample, variants reported | 10/1/2025 | |
| 0583U* | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome comparator DNA sequencing for single-nucleotide variants, insertions/deletions, copy number variations, blood, saliva, tissue sample, variants reported with proband results | 10/1/2025 | |
| 0585U* | Targeted genomic sequence analysis panel, solid organ neoplasm, circulating cell-free DNA (cfDNA) analysis from plasma of 521 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, and microsatellite instability, report | 10/1/2025 | 9/30/2026 |
Page 7 of 29
Code Code Description
Precert Effective Date Precert Removal Date
0586U*
Oncology, mRNA, gene expression profiling of 216 geOncology, mRNA, gene expression profiling of 216 genes (204 targeted and 12 housekeeping genes), RNA expression analysis, formalin- fixed paraffin-embedded (FFPE) tissue, quantitative, reported as log2 ratio per gene 10/1/2025 0592U* Oncology (hematolymphoid neoplasms), DNA, targeted genomic sequence of 417 genes, interrogation for gene fusions, translocations, rearrangements, utilizing formalin-fixed paraffin- embedded (FFPE) tumor tissue, results report clinically significant variant(s) 10/1/2025 0597U* Oncology (breast), RNA expression profiling of 329 genes by targeted nextgeneration sequencing and 20 proteins by multiplex immunofluorescence, formalin-fixed paraffin- embedded (FFPE) tissue, algorithmic analyses to determine tumor-recurrence risk score 10/1/2025 0623T* Automated quantification and characterization of coronary atherosclerotic plaque to assess severity of coronary disease, using data from coronary computed tomographic angiography; data preparation and transmission, computerized analysis of data, with review of computerized analysis output to reconcile discordant data, interpretation and report 1/1/2021 12/31/2025 0624T* Automated quantification and characterization of coronary atherosclerotic plaque to assess severity of coronary disease, using data from coronary computed tomographic angiography; data preparation and transmission 1/1/2021 12/31/2025 0625T* Automated quantification and characterization of coronary atherosclerotic plaque to assess severity of coronary disease, using data from coronary computed tomographic angiography; computerized analysis of data from coronary computed tomographic angiography 1/1/2021 12/31/2025 0626T* Automated quantification and characterization of coronary atherosclerotic plaque to assess severity of coronary disease, using data from coronary computed tomographic angiography; review of computerized analysis output to reconcile discordant data, interpretation and report 1/1/2021 12/31/2025 0720T Percutaneous electrical nerve field stimulation, cranial nerves, without implantation 7/1/2022 12/31/2025 0795T* Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; complete system (ie, right atrial and right ventricular pacemaker components) 7/1/2023 5/30/2025 0796T* Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right atrial pacemaker component (when an existing right ventricular single leadless pacemaker exists to create a dual-chamber leadless pacemaker system) 7/1/2023 5/30/2025 0797T* Transcatheter
insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right ventricular pacemaker component (when part of a dual-chamber leadless pacemaker system) 7/1/2023 5/30/2025
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 0801T | Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; dual-chamber system (ie, right atrial and right ventricular pacemaker components) | 7/1/2023 | 2/28/2025 |
| 0802T | Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right atrial pacemaker component | 7/1/2023 | 2/28/2025 |
| 0803T | Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right ventricular pacemaker component (when part of a dual-chamber leadless pacemaker system) | 1/1/2024 | 2/28/2025 |
| 0823T* | Transcatheter insertion of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculography, femoral venography, cavography) and device evaluation (eg, interrogation or programming), when performed | 1/1/2024 | 5/30/2025 |
| 0824T* | Transcatheter removal of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculography, femoral venography, cavography), when performed | 1/1/2024 | 5/30/2025 |
| 0825T* | Transcatheter removal and replacement of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculography, femoral venography, cavography) and device evaluation (eg, interrogation or programming), when performed | 1/1/2024 | 5/30/2025 |
| 0898T | Noninvasive prostate cancer estimation map, derived from augmentative analysis of image-guided fusion biopsy and pathology, including visualization of margin volume and location, with margin determination and physician interpretation and report | 7/1/2024 | 2/28/2025 |
| 0908T* | Open implantation of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed | 1/1/2025 | |
| 0933T* | Transcatheter implantation of wireless left atrial pressure sensor for long-term left atrial pressure monitoring, including sensor calibration and deployment, right heart catheterization, transseptal puncture, imaging guidance, and radiological supervision and interpretation | 1/1/2025 | |
| 0947T* | Magnetic resonance image guided low intensity focused ultrasound (MRgFUS), stereotactic blood-brain barrier disruption using microbubble resonators to increase the concentration of blood-based biomarkers of target, intracranial, including stereotactic navigation and frame placement, when performed | 1/1/2025 | |
| 0950T* | Ablation of benign prostate tissue, transrectal, with high intensity–focused ultrasound (HIFU), including ultrasound guidance | 7/1/2025 |
[*] Page 8 of 29
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 0951T* | Totally implantable active middle ear hearing implant; initial placement, including mastoidectomy, placement of and attachment to sound processor | 7/1/2025 | |
| 0956T* | Partial craniectomy, channel creation, and tunneling of electrode for sub scalp implantation of an electrode array, receiver, and telemetry unit for continuous bilateral electroencephalography monitoring system, including imaging guidance | 7/1/2025 | |
| 0957T* | Revision of sub-scalp implanted electrode array, receiver, and telemetry unit for electrode, when required, including imaging guidance | 7/1/2025 | |
| 0959T* | Removal or replacement of magnet from coil assembly that is connected to continuous bilateral electroencephalography monitoring system, including imaging guidance | 7/1/2025 | |
| 0960T* | Replacement of sub-scalp implanted electrode array, receiver, and telemetry unit with tunneling of electrode for continuous bilateral electroencephalography monitoring system, including imaging guidance | 7/1/2025 | |
| 0967T* | Transanal insertion of endoluminal temporary colorectal anastomosis protection device, including vacuum anchoring component and flexible sheath connected to external vacuum source and monitoring system | 7/1/2025 | |
| 0968T* | Insertion or replacement of epicranial neurostimulator system, including electrode array and pulse generator, with connection to electrode array | 7/1/2025 | |
| 0977T | Upper gastrointestinal blood detection, sensor capsule, with interpretation and report | 7/1/2025 | 9/12/2025 |
| 0978T* | Submucosal cryolysis therapy; soft palate, base of tongue, and lingual tonsil | 7/1/2025 | |
| 0979T* | Submucosal cryolysis therapy; soft palate only | 7/1/2025 | |
| 0980T* | Submucosal cryolysis therapy; base of tongue and lingual tonsil only (Do not report Submucosal cryolysis therapy; base of tongue and lingual tonsil only | 7/1/2025 | |
| 0981T* | Transcatheter implantation of wireless inferior vena cava sensor for long-term hemodynamic monitoring, including deployment of the sensor, radiological supervision and interpretation, right heart catheterization, and inferior vena cava venography, when performed | 7/1/2025 | |
| 15011* | Harvest of skin for skin cell suspension autograft; first 25 sq cm or less | 1/1/2025 | |
| 15012* | Harvest of skin for skin cell suspension autograft; each additional 25 sq cm or part thereof | 1/1/2025 | |
| 15013* | Preparation of skin cell suspension autograft, requiring enzymatic processing, manual mechanical disaggregation of skin cells, and filtration; first 25 sq cm or less of harvested skin | 1/1/2025 | |
| 15014* | Preparation of skin cell suspension autograft, requiring enzymatic processing, manual mechanical disaggregation of skin cells, and filtration; each additional 25 sq cm of harvested skin or part thereof | 1/1/2025 | |
| 15015* | Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, trunk, arms, legs; first 480 sq cm or less | 1/1/2025 | |
| 15016* | Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, trunk, arms, legs; each additional 480 sq cm or part thereof | 1/1/2025 | |
| 15017* | Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 480 sq cm or less | 1/1/2025 |
[*] Page 9 of 29
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 15018* | Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 480 sq cm or part thereof | 1/1/2025 | |
| 21032 | Excision of maxillary torus palatinus | 10/1/2006 | 2/28/2025 |
| 21181 | Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial | 8/19/2013 | 2/28/2025 |
| 21182 | Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less than 40 sq cm | 10/1/2006 | 2/28/2025 |
| 21280 | Medial canthopexy | 10/1/2006 | 2/28/2025 |
| 21282 | Lateral canthopexy | 10/1/2006 | 2/28/2025 |
| 21325 | Open treatment of nasal fracture; uncomplicated | 2/18/2013 | 10/17/2025 |
| 21347 | Open treatment of nasomaxillary complex fracture (LeFort II type); requiring multiple open approaches | 10/1/2006 | 2/28/2025 |
| 21348 | Open treatment of nasomaxillary complex fracture (LeFort II type); with bone grafting (includes obtaining graft) | 10/1/2006 | 2/28/2025 |
| 21432 | Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation | 10/1/2006 | 2/28/2025 |
| 21433 | Open treatment of craniofacial separation (LeFort III type); complicated (eg, comminuted or involving cranial nerve foramina), multiple surgical approaches | 10/1/2006 | 2/28/2025 |
| 21435 | Open treatment of craniofacial separation (LeFort III type); complicated, utilizing internal and/or external fixation techniques (eg, head cap, halo device, and/or intermaxillary fixation) | 10/1/2006 | 2/28/2025 |
| 21436 | Open treatment of craniofacial separation (LeFort III type); complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft) | 10/1/2006 | 2/28/2025 |
| 23106* | Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsy | 1/1/2016 | 12/30/2025 |
| 23802* | Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft) | 1/1/2016 | 12/30/2025 |
| 26341 | Manipulation, palmar fascial cord (ie, Dupuytren's cord), post enzyme injection (eg, collagenase), single cord | 8/6/2012 | 2/28/2025 |
| 27033* | Arthrotomy, hip, including exploration or removal of loose or foreign body | 1/1/2016 | 12/30/2025 |
| 27197 | Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, | 1/1/2017 | 7/25/2025 |
| 27331* | Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies | 1/1/2016 | 12/30/2025 |
| 27340* | Excision, prepatellar bursa | 1/1/2016 | 12/30/2025 |
| 27347* | Excision of lesion of meniscus or capsule (eg, cyst, ganglion), knee | 1/1/2016 | 12/30/2025 |
| 27407* | Repair, primary, torn ligament and/or capsule, knee; cruciate | 1/1/2016 | 12/30/2025 |
| 27409* | Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments | 1/1/2016 | 12/30/2025 |
| 27445* | Arthroplasty, knee, hinge prosthesis (eg, Walldius type) | 1/1/2016 | 12/30/2025 |
| 28291* | Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant | 11/20/2025 |
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 28446 | Open osteochondral autograft, talus (includes obtaining graft[s]) | 1/1/2008 | 4/25/2025 |
| 30520* | Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft | 10/17/2025 | |
| 31643* | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of catheter(s) for intracavitary radioelement application | 8/1/2012 | 5/30/2025 |
| 31647 | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve(s), initial lobe | 1/1/2013 | 2/28/2025 |
| 31660 | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe | 1/1/2013 | 2/28/2025 |
| 31661 | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes | 1/1/2013 | 2/28/2025 |
| 33206* | Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial | 2/1/2021 | 5/30/2025 |
| 33207* | Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular | 2/1/2021 | 5/30/2025 |
| 33208* | Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular | 2/1/2021 | 5/30/2025 |
| 33274* | Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed | 1/1/2019 | 5/30/2025 |
| 37220* | Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty | 4/1/2019 | 12/31/2025 |
| 37221* | Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed | 4/1/2019 | 12/31/2025 |
| 37222* | Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty | 4/1/2019 | 12/31/2025 |
| 37223* | Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed | 4/1/2019 | 12/31/2025 |
| 37224* | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty | 4/1/2019 | 12/31/2025 |
| 37225* | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed | 4/1/2019 | 12/31/2025 |
| 37226* | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed | 4/1/2019 | 12/31/2025 |
| 37227* | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed | 4/1/2019 | 12/31/2025 |
| 37228* | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty | 4/1/2019 | 12/31/2025 |
| 37229* | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed | 4/1/2019 | 12/31/2025 |
| 37230* | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed | 4/1/2019 | 12/31/2025 |
[*] Page 11 of 29
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 37231* | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed | 4/1/2019 | 12/31/2025 |
| 37232* | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty | 4/1/2019 | 12/31/2025 |
| 37233* | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed | 4/1/2019 | 12/31/2025 |
| 37234* | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed | 4/1/2019 | 12/31/2025 |
| 37235* | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed | 4/1/2019 | 12/31/2025 |
| 38225 | Chimeric antigen receptor T-cell (CAR-T) therapy; harvesting of blood-derived T lymphocytes for development of genetically modified autologous CAR-T cells, per day | 1/1/2025 | |
| 38226 | Chimeric antigen receptor T-cell (CAR-T) therapy; preparation of blood-derived T lymphocytes for transportation (eg, cryopreservation, storage) | 1/1/2025 | |
| 38227 | Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and preparation of CAR-T cells for administration | 1/1/2025 | |
| 38228 | Chimeric antigen receptor T-cell (CAR-T) therapy; CAR-T cell administration, autologous | 1/1/2025 | |
| 41820 | Gingivectomy, excision gingiva, each quadrant | 10/1/2006 | 2/28/2025 |
| 43200* | Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed | 1/1/2022 | 5/30/2025 |
| 43201* | Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance | 1/1/2022 | 5/30/2025 |
| 43202* | Esophagoscopy, flexible, transoral; with biopsy, single or multiple | 1/1/2022 | 5/30/2025 |
| 43204* | Esophagoscopy, flexible, transoral; with injection sclerosis of esophageal varices | 1/1/2022 | 5/30/2025 |
| 43205* | Esophagoscopy, flexible, transoral; with band ligation of esophageal varices | 1/1/2022 | 5/30/2025 |
| 43206* | Esophagoscopy, flexible, transoral; with optical endomicroscopy | 1/1/2022 | 5/30/2025 |
| 43211* | Esophagoscopy, flexible, transoral; with endoscopic mucosal resection | 1/1/2022 | 5/30/2025 |
| 43212* | Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) | 1/1/2022 | 5/30/2025 |
| 43213* | Esophagoscopy, flexible, transoral; with dilation of esophagus, by balloon or dilator, retrograde (includes fluoroscopic guidance, when performed) | 1/1/2022 | 5/30/2025 |
| 43214* | Esophagoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) | 1/1/2022 | 5/30/2025 |
| 43215* | Esophagoscopy, flexible, transoral; with removal of foreign body(s) | 1/1/2022 | 5/30/2025 |
[*] Page 12 of 29
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 43216* | Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps | 1/1/2022 | 5/30/2025 |
| 43217* | Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique | 1/1/2022 | 5/30/2025 |
| 43220* | Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation (less than 30 mm diameter) | 1/1/2022 | 5/30/2025 |
| 43226* | Esophagoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) over guide wire | 1/1/2022 | 5/30/2025 |
| 43227* | Esophagoscopy, flexible, transoral; with control of bleeding, any method | 1/1/2022 | 5/30/2025 |
| 43229* | Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) | 1/1/2022 | 5/30/2025 |
| 43246* | Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube | 1/1/2022 | 10/17/2025 |
| 43648 | Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum | 1/22/2007 | 2/28/2025 |
| 50380 | Renal autotransplantation, reimplantation of kidney | 10/1/2006 | 2/28/2025 |
| 51721* | Insertion of transurethral ablation transducer for delivery of thermal ultrasound for prostate tissue ablation, including suprapubic tube placement during the same session and placement of an endorectal cooling device, when performed | 7/25/2025 | |
| 53865* | Cystourethroscopy with insertion of temporary device for ischemic remodeling (ie, pressure necrosis) of bladder neck and prostate | 1/1/2025 | |
| 54408 | Repair of component(s) of a multi-component, inflatable penile prosthesis | 10/1/2006 | 9/12/2025 |
| 54410 | Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session | 10/1/2006 | 9/12/2025 |
| 54416 | Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session | 10/1/2006 | 9/12/2025 |
| 55881* | Ablation of prostate tissue, transurethral, using thermal ultrasound, including magnetic resonance imaging guidance for, and monitoring of, tissue ablation | 7/25/2025 | |
| 55882* | Ablation of prostate tissue, transurethral, using thermal ultrasound, including magnetic resonance imaging guidance for, and monitoring of, tissue ablation; with insertion of transurethral ultrasound transducer for delivery of thermal ultrasound, including suprapubic tube placement and placement of an endorectal cooling device, when performed | 7/25/2025 | |
| 60660* | Ablation of 1 or more thyroid nodule(s), one lobe or the isthmus, percutaneous, including imaging guidance, radiofrequency | 1/1/2025 | |
| 60661* | Ablation of 1 or more thyroid nodule(s), additional lobe, percutaneous, including imaging guidance, radiofrequency | 1/1/2025 | |
| 64561 | Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed | 1/1/2009 | 11/20/2025 |
| 64581 | Open implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) | 1/1/2009 | 11/20/2025 |
| 64804 | Sympathectomy, cervicothoracic | 10/1/2006 | 2/28/2025 |
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 66683* | Implantation of iris prosthesis, including suture fixation and repair or removal of iris, when performed | 1/1/2025 | |
| 70450* | Computed tomography, head or brain; without contrast material | 10/1/2006 | 5/30/2025 |
| 70460* | Computed tomography, head or brain; with contrast material(s) | 10/1/2006 | 5/30/2025 |
| 70470* | Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections | 10/1/2006 | 5/30/2025 |
| 70480* | Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material | 10/1/2006 | 5/30/2025 |
| 70481* | Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) | 10/1/2006 | 5/30/2025 |
| 70482* | Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections | 10/1/2006 | 5/30/2025 |
| 70486* | Computed tomography, maxillofacial area; without contrast material | 10/1/2006 | 5/30/2025 |
| 70487* | Computed tomography, maxillofacial area; with contrast material(s) | 10/1/2006 | 5/30/2025 |
| 70488* | Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections | 10/1/2006 | 5/30/2025 |
| 70496* | Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing | 10/1/2006 | 5/30/2025 |
| 70544* | Magnetic resonance angiography, head; without contrast material(s) | 10/1/2006 | 5/30/2025 |
| 70545* | Magnetic resonance angiography, head; with contrast material(s) | 10/1/2006 | 5/30/2025 |
| 70546* | Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences | 10/1/2006 | 5/30/2025 |
| 70551* | Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material | 10/1/2006 | 5/30/2025 |
| 70552* | Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s) | 10/1/2006 | 5/30/2025 |
| 70553* | Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences | 10/1/2006 | 5/30/2025 |
| 70554* | Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration | 1/22/2007 | 5/30/2025 |
| 70555* | Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing | 1/22/2007 | 5/30/2025 |
| 71271* | Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) | 1/1/2021 | 2/28/2025 |
| 74261* | Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material | 1/1/2010 | 5/30/2025 |
| 74262* | Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed | 1/1/2010 | 5/30/2025 |
| 74263* | Computed tomographic (CT) colonography, screening, including image postprocessing | 1/1/2010 | 5/30/2025 |
| 75557* | Cardiac magnetic resonance imaging for morphology and function without contrast material; | 1/1/2008 | 5/30/2025 |
| 75559* | Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging | 10/1/2006 | 5/30/2025 |
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 75561* | Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; | 1/1/2008 | 5/30/2025 |
| 75563* | Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging | 1/1/2008 | 5/30/2025 |
| 75565* | Cardiac magnetic resonance imaging for velocity flow mapping | 1/1/2010 | 5/30/2025 |
| 75571* | Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium | 1/1/2010 | 5/30/2025 |
| 75572* | Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed) | 1/1/2010 | 5/30/2025 |
| 75573* | Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of left ventricular [LV] cardiac function, right ventricular [RV] structure and function and evaluation of vascular structures, if performed) | 1/1/2010 | 5/30/2025 |
| 76380* | Computed tomography, limited or localized follow-up study | 10/1/2006 | 5/30/2025 |
| 77014* | Computed tomography guidance for placement of radiation therapy fields | 8/1/2012 | 12/31/2025 |
| 77078* | Computed tomography, bone mineral density study, 1 or more sites, axial skeleton (eg, hips, pelvis, spine) | 10/1/2006 | 2/28/2025 |
| 77385* | Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple | 1/1/2015 | 12/31/2025 |
| 77386* | Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex | 1/1/2015 | 12/31/2025 |
| 77401* | Radiation treatment delivery, superficial and/or ortho voltage, per day | 8/1/2012 | 12/31/2025 |
| 77600* | Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less) | 8/1/2012 | 5/30/2025 |
| 77605* | Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm) | 8/1/2012 | 5/30/2025 |
| 77610* | Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators | 8/1/2012 | 5/30/2025 |
| 77615* | Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators | 8/1/2012 | 5/30/2025 |
| 77620* | Hyperthermia generated by intracavitary probe(s) | 8/1/2012 | 5/30/2025 |
| 77750* | Infusion or instillation of radioelement solution (includes 3-month follow-up care) | 8/1/2012 | 11/20/2025 |
| 78451* | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) | 7/1/2011 | 5/30/2025 |
| 78452* | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection | 7/1/2011 | 5/30/2025 |
[*] Page 15 of 29
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 78453* | Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) | 7/1/2011 | 5/30/2025 |
| 78454* | Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection | 7/1/2011 | 5/30/2025 |
| 78456 | Acute venous thrombosis imaging, peptide | 8/17/2009 | 2/28/2025 |
| 78466* | Myocardial imaging, infarct avid, planar; qualitative or quantitative | 7/1/2011 | 5/30/2025 |
| 78468* | Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique | 7/1/2011 | 5/30/2025 |
| 78469* | Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification | 7/1/2011 | 5/30/2025 |
| 78472* | Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing | 7/1/2011 | 5/30/2025 |
| 78473* | Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification | 7/1/2011 | 5/30/2025 |
| 78481* | Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification | 7/1/2011 | 5/30/2025 |
| 78483* | Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification | 7/1/2011 | 5/30/2025 |
| 78494* | Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing | 7/1/2011 | 5/30/2025 |
| 78496* | Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique | 7/1/2011 | 5/30/2025 |
| 78499* | Unlisted cardiovascular procedure, diagnostic nuclear medicine | 10/1/2006 | 5/30/2025 |
| 79101* | Radiopharmaceutical, therapy, by intravenous administration | 10/17/2025 | |
| 81195* | Cytogenomic (genome-wide) analysis, hematologic malignancy, structural variants and copy number variants, optical genome mapping (OGM) | 1/1/2025 | |
| 81541* | Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score | 11/20/2025 | |
| 81558 | Transplantation medicine (allograft rejection, kidney), mRNA, gene expression profiling by quantitative polymerase chain reaction (qPCR) of 139 genes, utilizing whole blood, algorithm reported as a binary categorization as transplant excellence, which indicates immune quiescence, or not transplant excellence, indicating subclinical rejection | 1/1/2025 | |
| 86950 | Leukocyte transfusion | 1/1/1993 | 11/20/2025 |
[*] Page 16 of 29
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 90281 | Immune globulin (Ig), human, for intramuscular use | 8/19/2013 | 5/30/2025 |
| 90999 | Unlisted dialysis procedure, inpatient or outpatient | 1/1/1993 | 2/28/2025 |
| 91110* | Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and report | 1/1/2022 | 5/30/2025 |
| 91111* | Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus with interpretation and report | 1/1/2022 | 5/30/2025 |
| 91112* | Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report | 1/1/2013 | 5/30/2025 |
| 91113* | Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), colon, with interpretation and report | 1/1/2022 | 5/30/2025 |
| 92971 | Cardioassist-method of circulatory assist; external | 9/15/2010 | 2/28/2025 |
| 93350* | Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; | 2/17/2014 | 5/30/2025 |
| 93351* | Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional | 2/17/2014 | 5/30/2025 |
| 93583 | Percutaneous transcatheter septal reduction therapy (eg, alcohol septal ablation) including temporary pacemaker insertion when performed | 1/1/2017 | 7/25/2025 |
| 93593* | Right heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone; normal native connections | 1/1/2022 | 5/30/2025 |
| 93594* | Right heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone; abnormal native connections | 1/1/2022 | 5/30/2025 |
| 93595* | Left heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone, normal or abnormal native connections | 1/1/2022 | 5/30/2025 |
| 93596* | Right and left heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone(s); normal native connections | 1/1/2022 | 5/30/2025 |
| 93597* | Right and left heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone(s); abnormal native connections | 1/1/2022 | 5/30/2025 |
| 99500 | Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring | 10/25/2019 | 2/28/2025 |
| 99501 | Home visit for postnatal assessment and follow-up care | 10/25/2019 | 2/28/2025 |
| 99502 | Home visit for newborn care and assessment | 10/25/2019 | 2/28/2025 |
| 99503 | Home visit for respiratory therapy care (eg, bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation) | 10/25/2019 | 2/28/2025 |
| 99504 | Home visit for mechanical ventilation care | 10/25/2019 | 2/28/2025 |
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| 99505 | Home visit for stoma care and maintenance including colostomy and cystostomy | 10/25/2019 | 2/28/2025 |
| 99506 | Home visit for intramuscular injections | 10/25/2019 | 2/28/2025 |
| 99507 | Home visit for care and maintenance of catheter(s) (eg, urinary, drainage, and enteral) | 10/25/2019 | 2/28/2025 |
| 99509 | Home visit for assistance with activities of daily living and personal care | 10/25/2019 | 2/28/2025 |
| 99510 | Home visit for individual, family, or marriage counseling | 10/25/2019 | 2/28/2025 |
| 99511 | Home visit for fecal impaction management and enema administration | 10/25/2019 | 2/28/2025 |
| A0140 | Non-emergency transportation and air travel (private or commercial) intra or inter state | 1/1/2009 | 7/25/2025 |
| A4641 | Radiopharmaceutical, diagnostic, not otherwise classified | 2/17/2017 | 2/28/2025 |
| A9506 | Graphite crucible for preparation of technetium tc 99m-labeled carbon aerosol, one crucible | 7/1/2024 | 2/28/2025 |
| C1717 | Brachytherapy source, non-stranded, high dose rate iridium-192, per source | 8/1/2012 | 2/28/2025 |
| C1824 | Generator, cardiac contractility modulation (implantable) | 1/1/2020 | 12/30/2025 |
| C1825 | Generator, neurostimulator (implantable), non-rechargeable with carotid sinus baroreceptor stimulation lead(s) | 1/1/2021 | 12/30/2025 |
| C2616* | Brachytherapy source, non-stranded, yttrium-90, per source | 10/17/2025 | |
| C2643 | Brachytherapy source, non-stranded, cesium-131, per source | 8/1/2012 | 2/28/2025 |
| C2645 | Brachytherapy planar source, palladium-103, per square millimeter | 1/1/2016 | 2/28/2025 |
| C5271 | Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | 1/1/2014 | 12/31/2025 |
| C5273 | Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | 1/1/2014 | 12/31/2025 |
| C5275 | Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | 1/1/2014 | 12/31/2025 |
| C7504 | Percutaneous vertebroplasties (bone biopsies included when performed), first cervicothoracic and any additional cervicothoracic or lumbosacral vertebral bodies, unilateral or bilateral injection, inclusive of all imaging guidance | 1/1/2023 | 2/28/2025 |
| C7505 | Percutaneous vertebroplasties (bone biopsies included when performed), first lumbosacral and any additional cervicothoracic or lumbosacral vertebral bodies, unilateral or bilateral injection, inclusive of all imaging guidance | 1/1/2023 | 2/28/2025 |
| C7507 | Percutaneous vertebral augmentations, first thoracic and any additional thoracic or lumbar vertebral bodies, including cavity creations (fracture reductions and bone biopsies included when performed) using mechanical device (eg, kyphoplasty), unilateral or bilateral cannulations, inclusive of all imaging guidance | 1/1/2023 | 2/28/2025 |
| C7508 | Percutaneous vertebral augmentations, first lumbar and any additional thoracic or lumbar vertebral bodies, including cavity creations (fracture reductions and bone biopsies included when performed) using mechanical device (eg, kyphoplasty), unilateral or bilateral cannulations, inclusive of all imaging guidance | 1/1/2023 | 2/28/2025 |
"Cigna Companies" refers to operating subsidiaries of Cigna Corporation. All products and services are provided exclusively by or through such operating subsidiaries, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Evernorth Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. © 2026 Cigna.
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| C7557* | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed and intraprocedural coronary fractional flow reserve (ffr) with 3d functional mapping of color-coded ffr values for the coronary tree, derived from coronary angiogram data, for real-time review and interpretation of possible atherosclerotic stenosis(es) intervention | 1/1/2025 | |
| C8002* | Preparation of skin cell suspension autograft, automated, including all enzymatic processing and device components (do not report with manual suspension preparation) | 1/1/2025 | |
| C8003* | Implantation of medial knee extraarticular implantable shock absorber spanning the knee joint from distal femur to proximal tibia, open, includes measurements, positioning and adjustments, with imaging guidance (eg, fluoroscopy) | 1/1/2025 | |
| C9173* | Injection, filgrastim-txid (nypozi), biosimilar, 1 microgram | 1/1/2025 | 6/30/2025 |
| C9174* | Injection, datopotamab deruxtecan-dlnk, 1 mg | 7/1/2025 | 9/30/2025 |
| C9175* | Injection, treosulfan, 50 mg | 7/1/2025 | 9/30/2025 |
| C9301 | Obecabtagene autoleucel, up to 410 million cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose | 4/1/2025 | 6/30/2025 |
| C9302* | Injection, zanidatamab-hrii, 2 mg | 4/1/2025 | 6/30/2025 |
| C9303* | Injection, zolbetuximab-clzb, 1 mg | 4/1/2025 | 6/30/2025 |
| C9304 | Injection, marstacimab-hncq, 0.5 mg | 4/1/2025 | 6/30/2025 |
| C9305 | Injection, nipocalimab-aahu, 3 mg | 10/1/2025 | 12/31/2025 |
| C9306* | Injection, telisotuzumab vedotin-tllv, 1 mg | 10/1/2025 | 12/31/2025 |
| C9784 | Gastric restrictive procedure, endoscopic sleeve gastroplasty, with esophagogastroduodenoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components | 1/1/2025 | 12/31/2025 |
| C9785* | Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components | 1/1/2025 | |
| C9793* | 3d predictive model generation for pre-planning of a cardiac procedure, using data from cardiac computed tomographic angiography with report | 1/1/2025 | |
| C9796 | Repair of enterocutaneous fistula small intestine or colon (excluding anorectal fistula) with plug (e.g., porcine small intestine submucosa [sis]) | 4/1/2024 | 2/28/2025 |
| C9807* | Nerve stimulator, percutaneous, peripheral (e.g., sprint peripheral nerve stimulation system), including electrode and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023) | 1/1/2025 | |
| C9808* | Nerve cryoablation probe (e.g., cryoice, cryosphere, cryosphere max, cryoice cryosphere, cryoice cryo2), including probe and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023) | 1/1/2025 |
[*] Page 19 of 29
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| C9809* | Cryoneurolysis needle (e.g., iovera system), including needle/tip and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023) | 1/1/2025 | |
| D7880 | occlusal orthotic device, by report | 1/1/2001 | 7/25/2025 |
| D7881 | occlusal orthotic device adjustment | 1/1/2016 | 2/28/2025 |
| E0736 | Transcutaneous tibial nerve stimulator | 4/1/2024 | 10/17/2025 |
| E1399* | Durable medical equipment, miscellaneous | 1/1/2025 | |
| E3200 | Gait modulation system, rhythmic auditory stimulation, including restricted therapy software, all components and accessories, prescription only | 10/1/2024 | 12/30/2025 |
| G0051 | Patients under hospice care in the current reporting month | 1/1/2022 | 2/28/2025 |
| G0155 | Services of clinical social worker in home health or hospice settings, each 15 minutes | 10/25/2019 | 7/25/2025 |
| G0156 | Services of home health/hospice aide in home health or hospice settings, each 15 minutes | 10/25/2019 | 7/25/2025 |
| G0299 | Direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes | 10/25/2019 | 7/25/2025 |
| G0300 | Direct skilled nursing services of a licensed practical nurse (lpn) in the home health or hospice setting, each 15 minutes | 10/25/2019 | 7/25/2025 |
| G0337 | Hospice evaluation and counseling services, pre-election | 1/1/2005 | 7/25/2025 |
| G0493 | Skilled services of a registered nurse (rn) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting) | 1/1/2017 | 7/25/2025 |
| G0494 | Skilled services of a licensed practical nurse (lpn) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting) | 1/1/2017 | 7/25/2025 |
| G0555* | Provision of replacement patient electronics system (e.g., system pillow, handheld reader) for home pulmonary artery pressure monitoring | 1/1/2025 | |
| G0564 | Creation of subcutaneous pocket with insertion of 365 day implantable interstitial glucose sensor, including system activation and patient training | 1/1/2025 | 3/31/2025 |
| G6001* | Ultrasonic guidance for placement of radiation therapy fields | 1/1/2015 | 12/31/2025 |
| G6002* | Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy | 1/1/2015 | 12/31/2025 |
| G6003* | Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: up to 5 mev | 1/1/2015 | 12/31/2025 |
[*] Page 20 of 29
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| G6004* | Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 6-10 mev | 1/1/2015 | 12/31/2025 |
| G6005* | Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 11-19 mev | 1/1/2015 | 12/31/2025 |
| G6006* | Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 20 mev or greater | 1/1/2015 | 12/31/2025 |
| G6007* | Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: up to 5 mev | 1/1/2015 | 12/31/2025 |
| G6008* | Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 6-10 mev | 1/1/2015 | 12/31/2025 |
| G6009* | Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 11-19 mev | 1/1/2015 | 12/31/2025 |
| G6010* | Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 20 mev or greater | 1/1/2015 | 12/31/2025 |
| G6011* | Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 mev | 1/1/2015 | 12/31/2025 |
| G6012* | Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 mev | 1/1/2015 | 12/31/2025 |
| G6013* | Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 mev | 1/1/2015 | 12/31/2025 |
| G6014* | Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20 mev or greater | 1/1/2015 | 12/31/2025 |
| G6015* | Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic mlc, per treatment session | 1/1/2015 | 12/31/2025 |
| G6016* | Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session | 1/1/2015 | 12/31/2025 |
| G6017* | Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg,3d positional tracking, gating, 3d surface tracking), each fraction of treatment | 1/1/2015 | 12/31/2025 |
| G9687 | Hospice services provided to patient any time during the measurement period | 1/1/2017 | 2/28/2025 |
| G9690 | Patient receiving hospice services any time during the measurement period | 1/1/2019 | 2/28/2025 |
| G9720 | Hospice services for patient occurred any time during the measurement period | 1/1/2017 | 2/28/2025 |
[*] Page 21 of 29
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| G9758 | Patient in hospice at any time during the measurement period | 1/1/2018 | 2/28/2025 |
| G9858 | Patient enrolled in hospice | 1/1/2017 | 2/28/2025 |
| G9860 | Patient spent less than three days in hospice care | 1/1/2017 | 2/28/2025 |
| G9861 | Patient spent greater than or equal to three days in hospice care | 1/1/2017 | 2/28/2025 |
| H0046 | Mental health services, not otherwise specified | 2/17/2017 | 4/25/2025 |
| H2019 | Therapeutic behavioral services, per 15 minutes | 8/26/2016 | 4/25/2025 |
| J0139 | Injection, adalimumab, 1 mg | 1/1/2025 | |
| J0172 | Injection, aducanumab-avwa, 2 mg | 1/1/2022 | 12/31/2025 |
| J0185* | Injection, aprepitant, 1 mg | 1/1/2019 | 5/30/2025 |
| J0205 | Injection, alglucerase, per 10 units | 1/1/2010 | 12/31/2025 |
| J0215 | Injection, alefacept, 0.5 mg | 1/1/2004 | 12/31/2025 |
| J0570 | Buprenorphine implant, 74.2 mg | 10/1/2025 | |
| J0614* | Injection, treosulfan, 50 mg | 10/1/2025 | |
| J0738 | Injection, lenacapavir, 1 mg, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment for hiv) | 10/1/2025 | 12/31/2025 |
| J0739 | Injection, cabotegravir, 1mg, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment for hiv) | 7/1/2022 | 12/31/2025 |
| J0870* | Injection, imetelstat, 1 mg | 1/1/2025 | |
| J1072 | Injection, testosterone cypionate (azmiro), 1 mg | 4/1/2025 | |
| J1299 | Injection, eculizumab, 2 mg | 4/1/2025 | |
| J1300 | Injection, eculizumab, 10 mg | 5/1/2011 | 3/31/2025 |
| J1307 | Injection, crovalimab-akkz, 10 mg | 1/1/2025 | |
| J1326* | Injection, zolbetuximab-clzb, 2 mg | 7/1/2025 | |
| J1414 | Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose | 1/1/2025 | |
| J1434* | Injection, fosaprepitant (focinvez), 1 mg | 4/1/2024 | 5/30/2025 |
| J1453* | Injection, fosaprepitant, 1 mg - Brand name: EMEND | 1/1/2018 | 5/30/2025 |
| J1454* | Injection, fosnetupitant 235 mg and palonosetron 0.25 mg | 1/1/2019 | 5/30/2025 |
| J1456* | Injection, fosaprepitant (teva), not therapeutically equivalent to J1453, 1 mg | 1/1/2023 | 5/30/2025 |
| J1552 | Injection, immune globulin (alyglo), 100 mg | 1/1/2025 | |
| J1562 | Injection, immune globulin (vivaglobin), 100 mg | 1/1/2007 | 12/31/2025 |
| J1620 | Injection, gonadorelin hydrochloride, per 100 mcg | 10/1/2006 | 12/31/2025 |
| J1627* | Injection, granisetron, extended-release, 0.1 mg | 1/1/2018 | 5/30/2025 |
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| J1809 | Injection, fosdenopterin, 0.1 mg | 10/1/2025 | |
| J2351 | Injection, ocrelizumab, 1 mg and hyaluronidase-ocsq | 4/1/2025 | |
| J2468* | Injection, palonosetron hydrochloride (avyxa), not therapeutically equivalent to j2469, 25 micrograms | 7/1/2024 | 5/30/2025 |
| J2469* | Injection, palonosetron hcl, 25 mcg | 1/1/2018 | 5/30/2025 |
| J2503 | Injection, pegaptanib sodium, 0.3 mg | 8/6/2012 | 9/30/2025 |
| J2504 | Injection, pegademase bovine, 25 iu | 2/18/2013 | 12/31/2025 |
| J2802* | Injection, romiplostim, 1 microgram | 1/1/2025 | |
| J2940 | Injection, somatrem, 1 mg | 1/1/2002 | 12/31/2025 |
| J3355 | Injection, urofollitropin, 75 iu | 1/1/2006 | 12/31/2025 |
| J3391 | Injection, atidarsagene autotemcel, per treatment | 7/1/2025 | |
| J3392 | Injection, exagamglogene autotemcel, per treatment | 1/1/2025 | |
| J3402 | Injection, remestemcel-l-rknd, per therapeutic dose | 10/1/2025 | |
| J3403 | Revakinagene taroretcel-lwey, per implant | 10/1/2025 | |
| J7172 | Injection, marstacimab-hncq, 0.5 mg | 7/1/2025 | |
| J7173 | Injection, concizumab-mtci, 0.5 mg | 10/1/2025 | |
| J7174 | Injection, fitusiran, 0.04 mg | 10/1/2025 | |
| J7213 | Injection, coagulation factor ix (recombinant), ixinity, 1 i.u. | 7/1/2025 | |
| J7356 | Injection, foscarbidopa 0.25 mg/foslevodopa 5 mg | 7/1/2025 | |
| J7799 | Noc drugs, other than inhalation drugs, administered through dme | 8/27/2009 | 9/12/2025 |
| J9011* | Injection, datopotamab deruxtecandlnk, 1 mg | 10/1/2025 | |
| J9019* | Injection, asparaginase (erwinaze), 1,000 iu | 1/1/2013 | 12/31/2025 |
| J9024* | Injection, atezolizumab, 5 mg and hyaluronidase-tqjs | 4/1/2025 | |
| J9026* | Injection, tarlatamab-dlle, 1 mg | 1/1/2025 | |
| J9028* | Injection, nogapendekin alfa inbakicept-pmln, for intravesical use, 1 microgram | 1/1/2025 | |
| J9037* | Injection, belantamab mafodotin-blmf, 0.5 mg | 4/1/2021 | 3/31/2025 |
| J9038 | Injection, axatilimab-csfr, 0.1 mg | 4/1/2025 | |
| J9054* | Injection, bortezomib (boruzu), 0.1 mg | 4/1/2025 | |
| J9098* | Injection, cytarabine liposome, 10 mg | 1/1/2018 | 12/31/2025 |
| J9161* | Injection, denileukin diftitox-cxdl, 1 mcg | 4/1/2025 |
[*] Page 23 of 29
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| J9174* | Injection, docetaxel (beizray), 1 mg | 7/1/2025 | |
| J9212 | Injection, interferon alfacon-1, recombinant, 1 microgram | 1/1/2018 | 12/31/2025 |
| J9247* | Injection, melphalan flufenamide, 1mg | 10/1/2021 | 3/31/2025 |
| J9275* | Injection, cosibelimab-ipdl, 2 mg | 7/1/2025 | |
| J9276* | Injection, zanidatamab-hrii, 2 mg | 7/1/2025 | |
| J9289* | Injection, nivolumab, 2 mg and hyaluronidase-nvhy | 7/1/2025 | |
| J9292* | Injection, pemetrexed (avyxa), not therapeutically equivalent to J9305, 10 mg | 1/1/2025 | |
| J9340* | Injection, thiotepa, 15 mg - Brand name: THIOTEPA | 1/1/2018 | 6/30/2025 |
| J9341* | Injection, thiotepa (tepylute), 1 mg | 7/1/2025 | |
| J9342* | Injection, thiotepa, not otherwise specified, 1 mg | 7/1/2025 | |
| J9382* | Injection, zenocutuzumab-zbco, 1 mg | 7/1/2025 | |
| K1007* | Bilateral hip, knee, ankle, foot device, powered, includes pelvic component, single or double upright(s), knee joints any type, with or without ankle joints any type, includes all components and accessories, motors, microprocessors, sensors | 5/30/2025 | |
| K1035 | Molecular diagnostic test reader, nonprescription self-administered and self-collected use, fda approved, authorized or cleared | 4/28/2023 | 2/28/2025 |
| L5827* | Endoskeletal knee-shin system, single axis, electromechanical swing and stance phase control, with or without shock absorption and stance extension damping | 4/1/2025 | |
| L6700* | Upper extremity addition, external powered feature, myoelectronic control module, additional emg inputs, pattern-recognition decoding intent movement | 4/1/2025 | |
| M0235 | Intravenous infusion, monoclonal antibody products with an indication for post-exposure prophylaxis or treatment of COVID-19, for hospitalized adults and/or pediatric patients who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, includes infusion and post administration monitoring, not otherwise classified, first dose | 10/1/2025 | |
| M0236 | Intravenous infusion, monoclonal antibody products with an indication for post-exposure prophylaxis or treatment of COVID-19, for hospitalized adults and/or pediatric patients who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, includes infusion and post administration monitoring, not otherwise classified, second dose | 10/1/2025 | |
| M0237 | Intravenous infusion, tocilizumab-anoh, for hospitalized adult patients with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, includes infusion and post administration monitoring, first dose | 10/1/2025 |
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| M0238 | Intravenous infusion, tocilizumab-anoh, for hospitalized adult patients with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, includes infusion and post administration monitoring, second dose | 10/1/2025 | |
| Q0235 | Injection, monoclonal antibody products with an indication for post-exposure prophylaxis or treatment of COVID-19, for hospitalized adults and/or pediatric patients who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, not otherwise classified, 1 mg | 10/1/2025 | |
| Q0237 | Injection, tocilizumab-anoh, for hospitalized adult patients with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, 1 mg | 10/1/2025 | |
| Q2017* | Injection, teniposide, 50 mg | 1/1/2018 | 12/31/2025 |
| Q2057 | Afamitresgene autoleucel, including leukapheresis and dose preparation procedures, per therapeutic dose | 4/1/2025 | |
| Q2058 | Obecabtagene autoleucel, up to 400 million cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose | 7/1/2025 | |
| Q4082 | Drug or biological, not otherwise classified, part b drug competitive acquisition program (cap) | 1/1/2007 | 3/28/2025 |
| Q4100 | Skin substitute, not otherwise specified | 1/1/2009 | 12/31/2025 |
| Q4106 | Dermagraft, per square centimeter | 2/18/2013 | 12/31/2025 |
| Q4107 | Graftjacket, per square centimeter | 1/1/2009 | 4/25/2025 |
| Q4110 | Primatrix, per square centimeter | 1/1/2009 | 4/25/2025 |
| Q4121 | Theraskin, per square centimeter | 2/6/2012 | 4/25/2025 |
| Q4361* | Epiexpress, per square centimeter | 4/1/2025 | |
| Q4383* | Axolotl graft ultra, per square centimeter | 10/1/2025 | |
| Q4385* | Apollo ft, per square centimeter | 10/1/2025 | |
| Q4386* | Acesso trifaca, per square centimeter | 10/1/2025 | |
| Q4388* | Neothelium 4l, per square centimeter | 10/1/2025 | |
| Q4389* | Neothelium 4l plus, per square centimeter | 10/1/2025 | |
| Q4392* | Grafix duo, per square centimeter | 10/1/2025 | |
| Q4393* | Surgraft ac, per square centimeter | 10/1/2025 | |
| Q4394* | Surgraft aca, per square centimeter | 10/1/2025 | |
| Q4395* | Acelagraft, per square centimeter | 10/1/2025 | |
| Q4396* | Natalin, per square centimeter | 10/1/2025 | |
| Q4397* | Summit aaa, per square centimeter | 10/1/2025 | |
| Q5001 | Hospice or home health care provided in patient's home/residence | 2/16/2015 | 7/25/2025 |
| Q5002 | Hospice or home health care provided in assisted living facility | 2/16/2015 | 7/25/2025 |
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| Q5003 | Hospice care provided in nursing long term care facility (ltc) or non-skilled nursing facility (nf) | 2/16/2015 | 7/25/2025 |
| Q5009 | Hospice or home health care provided in place not otherwise specified (nos) | 2/16/2015 | 7/25/2025 |
| Q5010 | Hospice home care provided in a hospice facility | 10/1/2010 | 7/25/2025 |
| Q5098 | Injection, ustekinumab-srlf (imuldosa), biosimilar, 1 mg | 7/1/2025 | |
| Q5099 | Injection, ustekinumab-stba (steqeyma), biosimilar, 1 mg | 7/1/2025 | |
| Q5100 | Injection, ustekinumab-kfce (yesintek), biosimilar, 1 mg | 7/1/2025 | |
| Q5109 | Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg | 1/1/2019 | 12/31/2025 |
| Q5139 | Injection, eculizumab-aeeb (bkemv), biosimilar, 10 mg | 1/1/2025 | 3/31/2025 |
| Q5140 | Injection, adalimumab-fkjp, biosimilar, 1 mg | 1/1/2025 | |
| Q5141 | Injection, adalimumab-aaty, biosimilar, 1 mg | 1/1/2025 | |
| Q5142 | Injection, adalimumab-ryvk biosimilar, 1 mg | 1/1/2025 | |
| Q5143 | Injection, adalimumab-adbm, biosimilar, 1 mg | 1/1/2025 | |
| Q5144 | Injection, adalimumab-aacf (idacio), biosimilar, 1 mg | 1/1/2025 | |
| Q5145 | Injection, adalimumab-afzb (abrilada), biosimilar, 1 mg | 1/1/2025 | |
| Q5146* | Injection, trastuzumab-strf (hercessi), biosimilar, 10 mg | 1/1/2025 | |
| Q5147 | Injection, aflibercept-ayyh (pavblu), biosimilar, 1 mg | 4/1/2025 | |
| Q5148* | Injection, filgrastim-txid (nypozi), biosimilar, 1 microgram | 4/1/2025 | |
| Q5149 | Injection, aflibercept-abzv (enzeevu), biosimilar, 1 mg | 4/1/2025 | |
| Q5150 | Injection, aflibercept-mrbb (ahzantive), biosimilar, 1 mg | 4/1/2025 | |
| Q5151 | Injection, eculizumab-aagh (epysqli), biosimilar, 2 mg | 4/1/2025 | |
| Q5152 | Injection, eculizumab-aeeb (bkemv), biosimilar, 2 mg | 4/1/2025 | |
| Q5153 | Injection, aflibercept-yszy (opuviz), biosimilar, 1 mg | 7/1/2025 | |
| Q5154 | Injection, omalizumab-igec (omlyclo), biosimilar, 5 mg | 10/1/2025 | |
| Q5155 | Injection, aflibercept-jbvf (yesafili), biosimilar, 1 mg | 10/1/2025 | |
| Q5156* | Injection, tocilizumab-anoh (avtozma), biosimilar, 1 mg | 10/1/2025 | |
| Q5157* | Injection, denosumab-bmwo (stoboclo/osenvelt), biosimilar, 1 mg | 10/1/2025 | |
| Q5158* | Injection, denosumab-bnht (bomyntra/conexxence), biosimilar, 1 mg | 10/1/2025 | |
| Q5159* | Injection, denosumab-dssb (ospomyv/xbryk), biosimilar, 1 mg | 10/1/2025 | |
| Q9996 | Injection, ustekinumab-ttwe (pyzchiva), subcutaneous, 1 mg | 1/1/2025 | |
| Q9997 | Injection, ustekinumab-ttwe (pyzchiva), intravenous, 1 mg | 1/1/2025 | |
| Q9998 | Injection, ustekinumab-aekn (selarsdi), 1 mg | 1/1/2025 | |
| Q9999 | Injection, ustekinumab-aauz (otulfi), biosimilar, 1 mg | 4/1/2025 | |
| S0013 | Esketamine, nasal spray, 1 mg | 1/1/2021 | 12/31/2025 |
| S0148* | Injection, pegylated interferon alfa-2b, 10 mcg | 10/1/2010 | 6/27/2025 |
| S0189 | Testosterone pellet, 75 mg | 8/25/2017 | 12/31/2025 |
| S0255 | Hospice referral visit (advising patient and family of care options) performed by nurse, social worker, or other designated staff | 1/1/2002 | 7/25/2025 |
| S0271 | Physician management of patient home care, hospice monthly case rate (per 30 days) | 4/1/2007 | 2/28/2025 |
| S9125 | Respite care, in the home, per diem | 2/16/2015 | 12/30/2025 |
| S9126 | Hospice care, in the home, per diem | 2/16/2015 | 7/25/2025 |
| S9127 | Social work visit, in the home, per diem | 10/25/2019 | 2/28/2025 |
| S9325 | Home infusion therapy, pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9326 | Home infusion therapy, continuous (twenty-four hours or more) pain management infusion; administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9327 | Home infusion therapy, intermittent (less than twenty-four hours) pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9328 | Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9336 | Home infusion therapy, continuous anticoagulant infusion therapy (e.g., heparin), administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9340 | Home therapy; enteral nutrition; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9342 | Home therapy; enteral nutrition via pump; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9343 | Home therapy; enteral nutrition via bolus; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9346 | Home infusion therapy, alpha-1-proteinase inhibitor (e.g., prolastin); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9347 | Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or subcutaneous infusion therapy (e.g., epoprostenol); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9348 | Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e.g., dobutamine); administrative services, professional pharmacy services, care coordination, all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| S9351 | Home infusion therapy, continuous or intermittent anti-emetic infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9353 | Home infusion therapy, continuous insulin infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9355 | Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 3/28/2025 |
| S9357 | Home infusion therapy, enzyme replacement intravenous therapy; (e.g., imiglucerase); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9359 | Home infusion therapy, anti-tumor necrosis factor intravenous therapy; (e.g., infliximab); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9361 | Home infusion therapy, diuretic intravenous therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9363 | Home infusion therapy, anti-spasmotic therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9364 | Home infusion therapy, total parenteral nutrition (tpn); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard tpn formula, per diem | 1/1/2002 | 2/28/2025 |
| S9365 | Home infusion therapy, total parenteral nutrition (tpn); one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard tpn formula, per diem | 1/1/2002 | 2/28/2025 |
| S9366 | Home infusion therapy, total parenteral nutrition (tpn); more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard tpn formula, per diem | 1/1/2002 | 2/28/2025 |
| S9367 | Home infusion therapy, total parenteral nutrition (tpn); more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard tpn formula, per diem | 1/1/2002 | 2/28/2025 |
| S9368 | Home infusion therapy, total parenteral nutrition (tpn); more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard tpn formula, per diem | 1/1/2002 | 2/28/2025 |
| S9370 | Home therapy, intermittent anti-emetic injection therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9372 | Home therapy; intermittent anticoagulant injection therapy (e.g., heparin); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
| S9379 | Home infusion therapy, infusion therapy, not otherwise classified; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 1/1/2002 | 2/28/2025 |
[*] Page 28 of 29
| Code | Code Description | Precert Effective Date | Precert Removal Date |
|---|---|---|---|
| S9563 | Home injectable therapy, immunotherapy, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem | 4/28/2023 | 2/28/2025 |
| S9975 | Transplant related lodging, meals and transportation, per diem | 4/1/2002 | 10/17/2025 |
| T2042 | Hospice routine home care; per diem | 10/1/2003 | 2/28/2025 |
| T2043 | Hospice continuous home care; per hour | 10/1/2003 | 2/28/2025 |
Note from RegAlert. AI assistants can read this document in full, and search 70,000+ more, through the RegAlert MCP connector (https://mcp.regalert.today/mcp). Free with an account. How to connect ChatGPT, Claude or Cursor.
Annotations and obligations
571 definitions · 2 reporting items
- Definition / condition 571
- Reporting template 2
- background, boilerplate
More like this from DFR
DFR published 8 documents in the last 30 days. We email you each new one the day it's published.
Source: Vermont Department of Financial Regulation — original document · Summary generated with machine assistance and reviewed before publication; the authoritative text is the regulator's original document. How RegAlert works
In RegAlert: added · updated