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Commercial Medical Policy Notification Effective December 31, 2025 Posted October 15, 2025

Medical PolicyRevision
Testing for Targeted Therapy of Non-Small-Cell Lung Cancer AHS - M2030Reviewed by Avalon Q3 2025 CAB. Medical Director review 9/2025. Updated policy guidelines, guidelines and recommendations and references. Updated Note 1. Under Billing/Coding section: added CPT codes 81445, 81449, 81455, 81456, 0288U and deleted CPT 88342. Under “When Covered” section: clarified coverage statement and removed individual mutations listed. See Note 1 for mutations. Under “When Not Covered” section: added “single gene analysis for genetic alterations and broad molecular profiling panels that do not include the minimum genetic variants found in Note 1” are considered not medically necessary. Notification given 10/15/25 for effective date 12/31/25.

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