01IMMEDIATE ACTIONS REQUIRED - Multiple effective dates:
By October 1, 2026: Billing team must remove prior authorization requirements for in-lab sleep studies (CPT 95805, 95808, 95810, 95811) in the billing system for Commercial Products only.
02Update encounter forms and authorization workflows to reflect that these codes no longer require prior auth for commercial plans.
03By November 1, 2026.
04Billing team must update system rules to redirect molecular testing codes 0360U, 0080U, 0092U, and 81479 (Percepta Bronchial Genomic Classifier) to reference the new Biomarker Testing Mandate policy instead of the pulmonary nodules policy - no coverage changes but system logic must be updated.
05Update shoulder replacement authorization logic: Prior authorization remains required for CPT 23470 and 23472 for Medicare Advantage plans and is recommended for Commercial Products, but system must use REVISED medical criteria from the new policy instead of existing authorization tool criteria.
06For genetic testing (CPT 81479): Remove obsolete Genecept Assay and add OptimalRx Plus (Dynacare Plus) to system.
07Flag as NOT COVERED for Medicare Advantage and NOT MEDICALLY NECESSARY for commercial - claims should be denied accordingly.
08Consolidate ProMark Risk Score policy (CPT 81479) in system with no coverage changes.
09Update Medicare Advantage policy language for LTACH admissions to reflect that coverage may change per Medicare determination.
10Providers must be notified: Prior authorization requirements changed for shoulder procedures (23470, 23472) with new medical criteria - training required.
11Sleep study prior auth removed for commercial (95805, 95808, 95810, 95811).
12OptimalRx Plus is now covered test but with restrictions by plan type.
13Consequences of inaction: Claims for shoulder procedures using old criteria will be denied; sleep study claims will be denied if prior auth is obtained unnecessarily for commercial; OptimalRx Plus claims without proper coverage determination will be denied; claims for displaced molecular testing codes may be delayed or denied if not properly redirected.