Posted Feb 28, 2025
Starting June 1, 2025, Healthfirst will add prior authorization requirements for selected medical services. These changes are part of Healthfirst’s ongoing responsibility to evaluate its medical policies compared to the latest scientific evidence and specialty society guidance.
A printable PDF is available here.
Meanwhile, prior-authorization requirements may be added/updated/removed for certain codes, and post-service determinations may still be applicable based on criteria published in medical policies or local/national coverage determination criteria.
Note: Any authorization on file at this time will remain effective until the next authorization is required. As of June 1, 2025, authorization requests will be reviewed under the new authorization guidelines.
| Code | Code Type | Description | Authorization Managed By |
|---|---|---|---|
| 0532U | CPT | 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 | EviCore |
| 0533U | CPT | 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 | EviCore |
| 0534U | CPT | Oncology (prostate), microRNA, single-nucleotide polymorphisms (SNPs) analysis by RT-PCR of 32 variants, using buccal swab, algorithm reported as a risk score | EviCore |
| 0536U | CPT | Red blood cell antigen (fetal RhD), PCR analysis of exon 4 of RHD gene and housekeeping control gene GAPDH from whole blood in pregnant individuals at 10+ weeks gestation known to be RhD negative, reported as fetal RhD status | EviCore |
| 0537U | CPT | Oncology (colorectal cancer), analysis of cell-free DNA for epigenomic patterns, nextgeneration sequencing, >2500 differentially methylated regions (DMRs), plasma, algorithm reported as positive or negative | EviCore |
| 0538U | CPT | Oncology (solid tumor), nextgeneration targeted sequencing analysis, formalin-fixed paraffinembedded (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 | EviCore |
| 0539U | CPT | Oncology (solid tumor), cellfree circulating tumor DNA (ctDNA), 152 genes, nextgeneration sequencing, interrogation for singlenucleotide variants, insertions/deletions, gene rearrangements, copy number alterations, and microsatellite instability, using whole-blood samples, mutations with clinical actionability reported as actionable variant | EviCore |
| 0540U | CPT | Transplantation medicine, quantification of donorderived cell-free DNA using next-generation sequencing analysis of plasma, reported as percentage of donorderived cell-free DNA to determine probability of rejection | EviCore |
| 0543U | CPT | Oncology (solid tumor), nextgeneration sequencing of DNA from formalin-fixed paraffin-embedded (FFPE) tissue of 517 genes, interrogation for singlenucleotide variants, multinucleotide variants, insertions and deletions from DNA, fusions in 24 genes and splice variants in 1 gene from RNA, and tumor mutation burden | EviCore |
| 0544U | CPT | Nephrology (transplant monitoring), 48 variants by digital PCR, using cell-free DNA from plasma, donorderived cell-free DNA, percentage reported as risk for rejection | EviCore |
| 0549U | CPT | Oncology (urothelial), DNA, quantitative methylated realtime 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) |
If you have any questions, please contact your Network Account Manager, or call Provider Services at 1-888-801-1660, Monday to Friday, 8:30am-5:30pm
Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”).
Released March 2025