A9579 Gad-base mr contrast nos,1mlInjection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml
A9579 payment limit: $1.435 per 1 ML, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.
50419-0323-11 Ambelvist, Bayer HealthCare Pharmaceuticals Inc.: 100 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-DOSE)70436-0121-31 Gadoteridol, Slate Run Pharmaceuticals: 25 billing units per package (5 VIAL, SINGLE-DOSE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-DOSE)70436-0121-33 Gadoteridol, Slate Run Pharmaceuticals: 50 billing units per package (5 VIAL, SINGLE-DOSE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-DOSE)70436-0121-34 Gadoteridol, Slate Run Pharmaceuticals: 75 billing units per package (5 VIAL, SINGLE-DOSE in 1 CARTON / 15 mL in 1 VIAL, SINGLE-DOSE)70436-0121-35 Gadoteridol, Slate Run Pharmaceuticals: 100 billing units per package (5 VIAL, SINGLE-DOSE in 1 CARTON / 20 mL in 1 VIAL, SINGLE-DOSE)00407-0690-05 Omniscan, GE Healthcare Inc.: 50 billing units per package00407-0690-10 Omniscan, GE Healthcare Inc.: 100 billing units per package (10 VIAL in 1 BOX / 10 mL in 1 VIAL)00407-0690-12 Omniscan, GE Healthcare Inc.: 100 billing units per package00407-0690-15 Omniscan, GE Healthcare Inc.: 150 billing units per package (10 VIAL in 1 BOX / 15 mL in 1 VIAL)00407-0690-17 Omniscan, GE Healthcare Inc.: 150 billing units per package00407-0690-20 Omniscan, GE Healthcare Inc.: 200 billing units per package (10 VIAL in 1 BOX / 20 mL in 1 VIAL)00407-0690-22 Omniscan, GE Healthcare Inc.: 200 billing units per package00407-0690-70 Omniscan, GE Healthcare Inc.: 1000 billing units per package00270-1111-01 Prohance, Bracco Diagnostics Inc.: 50 billing units per package (5 VIAL, SINGLE-DOSE in 1 BOX / 10 mL in 1 VIAL, SINGLE-DOSE)00270-1111-02 Prohance, Bracco Diagnostics Inc.: 75 billing units per package (5 VIAL, SINGLE-DOSE in 1 BOX / 15 mL in 1 VIAL, SINGLE-DOSE)00270-1111-03 Prohance, Bracco Diagnostics Inc.: 100 billing units per package (5 VIAL, SINGLE-DOSE in 1 BOX / 20 mL in 1 VIAL, SINGLE-DOSE)00270-1111-04 Prohance, Bracco Diagnostics Inc.: 25 billing units per package (5 VIAL, SINGLE-DOSE in 1 BOX / 5 mL in 1 VIAL, SINGLE-DOSE)00270-1111-85 Prohance, Bracco Diagnostics Inc.: 500 billing units per package (5 VIAL, PHARMACY BULK PACKAGE in 1 BOX / 100 mL in 1 VIAL, PHARMACY BULK PACKAGE)Status X: statutory exclusion, not paid under the PFS.
A9579 appears in 6 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Premera Blue Cross.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Endolymphatic Hydrops (Meniere's Disease) Tests (0571) | not covered | Sep 1, 2026 | payer 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 |
| Aetna | Rilonacept (Arcalyst) (0770) | listed, no stance | Sep 11, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Bone Mineral Density Studies (L.6.01.412) | covered if criteria are met | 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.