A9577 Inj multihanceInjection, gadobenate dimeglumine (multihance), per ml
A9577 payment limit: $1.804 per 1 ML, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.
00270-5164-12 Multihance, Bracco Diagnostics Inc.: 25 billing units per package (5 VIAL, SINGLE-DOSE in 1 BOX / 5 mL in 1 VIAL, SINGLE-DOSE)00270-5164-13 Multihance, Bracco Diagnostics Inc.: 50 billing units per package (5 VIAL, SINGLE-DOSE in 1 BOX / 10 mL in 1 VIAL, SINGLE-DOSE)00270-5164-14 Multihance, Bracco Diagnostics Inc.: 75 billing units per package (5 VIAL, SINGLE-DOSE in 1 BOX / 15 mL in 1 VIAL, SINGLE-DOSE)00270-5164-15 Multihance, Bracco Diagnostics Inc.: 100 billing units per package (5 VIAL, SINGLE-DOSE in 1 BOX / 20 mL in 1 VIAL, SINGLE-DOSE)Status X: statutory exclusion, not paid under the PFS.
A9577 appears in 3 coverage policies from Aetna, Premera Blue Cross.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) of the Spine (0236) | covered if criteria are met | Apr 9, 2026 | payer document |
| Aetna | Magnetic Resonance Imaging of the Cardiovascular System - Cardiac MRI (0520) | covered if criteria are met | Aug 20, 2026 | payer document |
| Premera Blue Cross | Preventive Care Procedure Code(s) | Comments | covered if criteria are met | Sep 21, 2026 | payer document |
Prior authorization required or conditional in IN.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.