The gapfill year has run its course for NN codes. We saw proposed prices in May, final pries in September. Five codes changed price (although one by only 5%). Get the spreadsheet on this page, scrolling down to "agenda & important materials."
I've put a summary spreadsheet in the cloud. I've included a fact-based "Tips and Tricks" section at bottom.
Chat GPT writes as follows:
CMS Final Gapfill Prices:
Five Increases Among 17 Tests
CMS’s 2026 gapfill pricing cycle, establishing rates for 2027, includes 17 test codes: two conventional CPT codes and 15 PLA codes. Five prices increased from proposed to final, while 12 remained unchanged. None decreased. The national median matches the MolDX price for each test.
The five increases range from 5% to 375%, with markedly different effects in dollars:
| Code | Test, abbreviated | Proposed | Final | Dollar increase | Percent increase |
|---|---|---|---|---|---|
| 81524 | CNS tumor methylation classification | $1,995.69 | $2,500.00 | $504.31 | 25.3% |
| 87182 | Carbapenemase detection | $9.65 | $31.75 | $22.10 | 229.0% |
| 0534U | Prostate cancer risk assessment | $464.88 | $489.68 | $24.80 | 5.3% |
| 0542U | Renal transplant allograft injury assessment | $218.32 | $1,037.91 | $819.59 | 375.4% |
| 0597U | Breast cancer recurrence risk, RNA and proteins | $2,510.21 | $3,873.00 | $1,362.79 | 54.3% |
The largest dollar increase went to 0597U, up $1,363 per test. The largest percentage increase went to 0542U, whose final price is approximately 4.75 times the proposed amount. By comparison, 87182 more than tripled but gained only $22.10. The change for 0534U was modest: $24.80, or 5.3%.
MolDX supplied a rationale for each revision:
81524: The increase better reflects similar existing services, specifically 0020M.
87182: Updated information supported a higher price reflecting the resources required to perform the test.
0534U: MolDX considered updated gapfill information, stated that the code descriptor does not accurately reflect the test performed, and used 0401U as a crosswalk based on comparable methodology.
0542U: Newly provided gapfill documentation supported an increase reflecting the resources required to perform the test.
0597U: MolDX moved away from 81520 as the pricing comparator, instead referencing 81518, 81519, and 81521 to better reflect typical rates for similar services.
The rationales fall into two practical groups: new information about testing resources supported two increases, while comparisons with existing services supported three.
Most prices held steady, but revised documentation and a different choice of comparator produced substantial increases for several tests.
TIPS & TRICKS
Let's say you're sure your test is worth $3000 but MolDx priced at $2050. Based on the rationales here, how should you approach an appeal?
Make the case for the missing $950 using documented resources and well-chosen comparators. The five rationales suggest two productive approaches, although they do not reveal which arguments were submitted unsuccessfully.
Explain what the $2,050 valuation misses. Submit a clear accounting of the resources required to perform the test: labor, reagents, instrumentation, quality control, and analysis. Identify any omitted steps or incorrect assumptions in the original submission. For 87182 and 0542U, MolDX expressly attributed increases to updated information about required resources.
Show why approximately $3,000 is the better comparison. Identify existing services with comparable methodology, complexity, and resource requirements. Explain why those services are better benchmarks than the apparent $2,050 comparator. The 0597U rationale is particularly useful: MolDX explicitly replaced one comparator with a different group and raised the price by 54%.
Check whether the descriptor led to a misunderstanding. Explain precisely what the laboratory performs and how that maps to the code. For 0534U, MolDX flagged a mismatch between the descriptor and the actual test and selected a comparator based on methodology. That produced only a 5% increase, so clarification alone does not establish a $3,000 price.
The submission should make a reviewer’s decision straightforward: the current valuation, the specific assumption being challenged, the supporting evidence, and the calculation supporting the requested amount. A short comparison table and supporting documentation would do more work than a lengthy statement that the test is innovative or clinically valuable.
Moving from $2,050 to $3,000 requires a 46.3% increase—within the range of increases observed here. That establishes that a revision of this size is possible, not that it is likely. The strongest argument would show that both the resource evidence and the most appropriate existing comparators support approximately the same requested price.
