On September 9, 2025, CMS released proposed new lab test pricing for 2026, for public comment.
CMS also released final Gapfill pricing for 2026.
Go to the CMS annual public meeting lab website here:
Scroll down to Meeting Notice & Other Important Materials.
Under that, scroll to find CY2026 Preliminary Payment Determinations, and to find 2025 Final MAC Determinations.
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GAPFILL - FINAL
There were 34 codes under Gapfill.
Six codes for neurologic tests (amyloid, tau) rose from $70-93 to either $116 or $128.
Nine other codes raised in price got 130%, 211%, 125%, 244%, 1234% (!, 440U) 166%, 166%, 125%, 131%, 440U was a plasma metagenomic test that rose from $36 to $444, more than 10X.
In all, about half the codes (6+9=15, of 34) had price increases based on supplemental information provided over the summer.
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NEW CODES - PRELIMINARY
These are my manual tallies, so I could be off by one or two.
There were 90 codes in play. In 57, CMS agreed with the expert panel majority recommendation. In 34, they did not. Of those 34, only one agreed with a "substantial" minority vote of 4. Otherwise, CMS either disagreed with all the panelists or all but 1 of the panelists. Quite a few of these 34 were cases where CMS chose a proposal that no panelist had voted for and in some cases, CMS chose a proposal that had not even been mentioned in discussions.
I counted 21 of 90 prelminary proposals being for 2026 "Gapfill."
There was one case - 0523U, Item 26 - where CMS specifically chose an FDA-approved crosswalk for a new FDA-approved test. Pillar Oncoreveal CDx (22 genes). It is crosswalked to "0022U 81449". 0022U is $1950. 81449 is $597. CMS writes this as "0022U - 81449" with a dash or minus sign rather than a plus sign.
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BONUS - CMS Dislikes Fracitional Crosswalks
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At a talk on October 23, 2025, Erik Schulwolf of Hogan law firm had this quote from CMS on a slide:
CMS is permitted under the regulations to crosswalk to a fraction or multiple of a test on the CLFS
– Agency has in the past stated that “in an effort to maintain consistency across the entirety of recommendations, in most cases we support and recommend to crosswalk the new codes without multipliers”
I took a photo of the slide, uploaded to Chat GPT for a "transcript." I then plugged the quotation into Google, which gave me a "hit" for the quotation source - the CMS 2019 CLFS pricing decisions, made in about November 2018.
