`M0224` Pemivibart infusion

Intravenous infusion, pemivibart, for the pre-exposure prophylaxis only, for certain adults and adolescents (12 years of age and older weighing at least 40 kg) with no known sars-cov-2 exposure, who either have moderate-to-severe immune compromise due to a medical condition or receipt of immunosuppressive medications or treatments, includes infusion and post administration monitoring

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

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 1 units per day (policy), rationale: Code Descriptor / CPT Instruction
Outpatient hospital: max 1 units per day (policy), rationale: Code Descriptor / CPT Instruction

Medicare pricing for M0224

Physician Fee Schedule (CY 2026, RVU26D)

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

Payer policies and prior authorization for M0224

3 of 3 payer prior-auth lists that name M0224 require prior authorization or set conditions: Cigna.

Payer	Plan	State	Prior auth	Since	Source
Cigna	ACA/IFP	All	prior auth required	Sep 27, 2024	Master Precertification List (For Health Care Providers)
Cigna	Basic Standard	All	prior auth required	Sep 27, 2024	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	Sep 27, 2024	Master Precertification List (For Health Care Providers)

Payer coverage policies that name M0224

M0224 appears in 2 coverage policies from Blue Cross & Blue Shield of Mississippi, Premera Blue Cross.

Payer	Policy	Role in policy	Reviewed	Document
Blue Cross & Blue Shield of Mississippi	Treatment Of Coronavirus Disease 2019 Covid19 (L.2.01.431)	not covered		payer document
Premera Blue Cross	Non-covered Services and Procedures Page \| 17 of 30 \| ∞	not covered	Jun 1, 2026	payer document

Medicaid fee-for-service

IN: $360.70 (professional, Advanced Practice Nurse (85%), non-facility), effective Mar 22, 2024
KS: $0.00 (default), effective Jul 1, 2024
MD: $450.00 (covid_vaccines), effective Mar 22, 2024
MS: $450.50 (comprehensive), effective Jul 1, 2026
ND: $441.00 (physician), effective Aug 1, 2026
OH: $432.45 (provider_administered_drugs), effective May 16, 2024
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $195.00 (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.

M0224 Pemivibart infusion