`A9594` Gallium ga-68 psma-11, ucla

Gallium ga-68 psma-11, diagnostic, (ucla), 1 millicurie

Medicare coverage: Carrier judgment
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 7 units per day (clinical), rationale: Prescribing Information
Outpatient hospital: max 7 units per day (clinical), rationale: Prescribing Information

Medicare pricing for A9594

Physician Fee Schedule (CY 2026, RVU26D)

Status X: statutory exclusion, not paid under the PFS.

Payer policies and prior authorization for A9594

12 of 12 payer prior-auth lists that name A9594 require prior authorization or set conditions: CarePlus Health Plans, Humana.

Payer	Plan	State	Prior auth	Conditions	Since	Source
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Diagnostic Imaging	All	prior auth under conditions	site of care: office or outpatient		Humana Prior Authorization List (PAL): Diagnostic Imaging Services
Humana	Diagnostic Imaging	All	prior auth under conditions	site of care: office or outpatient		Humana Prior Authorization List (PAL): Diagnostic Imaging Services
Humana	Humana D-SNP (FL)	FL	prior auth required		Jan 1, 2027	1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
Humana	Humana D-SNP (IL)	IL	prior auth required		Jan 1, 2027	Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
Humana	Humana D-SNP (IN)	IN	prior auth required		Jan 1, 2027	*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
Humana	Humana D-SNP (MI)	MI	prior auth required		Jan 1, 2027	1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List
Humana	Humana D-SNP (SC)	SC	prior auth required		Jan 1, 2027	Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana MA and D-SNP	All	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana Puerto Rico MA and Dual Medicare-Medicaid	PR	prior auth required		Nov 3, 2025	Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
Humana	Oak Street Health	All	prior auth required			Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management

Payer coverage policies that name A9594

A9594 appears in 3 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Lutetium Lu 177 Dotatate (Lutathera) and Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto) (0929)	listed, no stance	Jul 17, 2026	payer document
Aetna	Positron Emission Tomography (PET) (0071)	covered if criteria are met	Sep 14, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Oncologic Applications Of Positron Emission Tomography Pet Scanning	covered if criteria are met		payer document

Recent prior-auth changes

Jan 1, 2023: PA added, humana:pa:commercial
Feb 23, 2022: PA removed, Blue Shield of California Promise Health Plan
Dec 1, 2021: PA added, Blue Shield of California Promise Health Plan

Medicaid fee-for-service

Prior authorization required or conditional in IN.

AZ: $345.33 (asc), effective Oct 1, 2026
KY: $363.50 (asc), effective Jan 1, 2026
MS: $297.74 (comprehensive, facility), effective Oct 1, 2025
NE: $813.40 (injectables), effective Jul 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $157.35 (outpatient_hospital_apc, Ambulatory Surgical Centers), effective Apr 1, 2026

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.

A9594 Gallium ga-68 psma-11, ucla