CPT 81353 is referenced in 7 tracked payer policy changes from Blue Cross Blue Shield of Rhode Island, Blue Shield of California, and 5 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 81353 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Multiple medical policy updates take effect July 1, 2025, affecting various testing services and prior authorization requirements. Key changes include biomarker testing moving from prior auth required to not covered for Medicare Advantage, phototherapy becoming covered for Medicare Advantage, and numerous genetic/molecular testing codes having prior authorization removed or coverage criteria changes.
Blue Shield of California's medical policy 2.04.151, Genetic Variant Testing (Including Liquid Biopsy) for Targeted Treatment in Advanced Cancer, lists the tumor tissue and liquid biopsy tests it may consider medically necessary to select FDA-approved targeted treatments. The policy states an effective date of November 1, 2026, and its policy history for that date says the policy statement, guidelines and literature were updated, the title changed from Genetic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Advanced Cancer, and a coding update was made. The policy refers to Appendix A for the policy statement changes from the previous version.
Genetic testing for TP53 may be considered medically necessary to confirm Li-Fraumeni syndrome in individuals who meet the classic or Chompret clinical diagnostic criteria, in individuals with early-onset breast cancer (age of diagnosis under 31 years), or in pediatric hypodiploid acute lymphoblastic leukemia. Targeted TP53 familial variant testing may be considered medically necessary in an at-risk relative of a proband with a known TP53 pathogenic variant, and genetic testing for a germline TP53 variant is investigational for all other indications. Effective 2026-10-01, the code reference was updated to remove an ICD-9 diagnosis code and add ICD-10 diagnosis codes QA1.790, QA1.791 and QA1.792.
Genetic testing for BRCA1, BRCA2, BRIP1, CDH1, PALB2, PTEN, RAD51C, RAD51D, STK11, or TP53 may be considered medically necessary when the policy criteria are met, such as a known familial pathogenic variant, a personal history of breast, pancreatic, ovarian, fallopian tube, or peritoneal cancer, or documented increased risk based on one of seven USPSTF-endorsed risk-stratification tools. Testing for these genes for hereditary breast or ovarian cancer risk is investigational for individuals who do not meet the criteria, and single gene or panel testing for other genes, including ATM, BARD1, and CHEK2, is investigational for hereditary breast, ovarian, and/or prostate cancer. This policy is effective June 1, 2026.
Excellus BlueCross BlueShield policy 2.02.60 considers germline genetic testing for hereditary cancer medically appropriate in listed circumstances, including when a blood relative has a known pathogenic or likely pathogenic variant, when a pathogenic or likely pathogenic variant is found on tumor genomic testing, when results aid systemic therapy or surgical decisions, and when individuals meet specific criteria for breast, ovarian, pancreatic, prostate, colorectal, Cowden syndrome, Li-Fraumeni syndrome, hereditary diffuse gastric cancer or familial medullary thyroid carcinoma. Multigene panel testing is considered medically appropriate when an individual meets Policy Statement I, except Policy Statements I.A, I.D and I.G.9. The current effective date is April 16, 2026, and the annual update kept the policy intent unchanged.
The IHCP reviewed the Outpatient Fee Schedule, found discrepancies, and will reflect the changes in the next regular update to that schedule. Codes listed twice on previous versions will appear only once, codes missing from the schedule are covered in the outpatient setting and can be billed for dates of service on or after the date listed for each code, and other listed codes are noncovered and will be added to the schedule. Codes that have been nationally end dated will be removed from the schedule, and Current Dental Terminology (CDT) codes cannot be billed on institutional claims (UB-04 claim form or electronic equivalent).
Effective January 1, 2021, Immune Globulin Therapy criteria changed so that preventive IVIG use after hematopoietic cell transplantation, in chronic lymphocytic leukemia, lymphoma, multiple myeloma and solid organ transplant became investigational, and IVIG for humoral immunodeficiency states now requires an IgG level below 400 mg/dL with persistent or recurrent infections. Effective January 1, 2021, the Drugs for Weight Management policy was added for Contrave, Qsymia, Saxenda and Xenical for groups that cover weight loss drugs, and the Exception Request policy for Washington fully insured members was added. Coding updates made CPT 69705, 69706 and 55880, and HCPCS Q5122, J9316, J7352, J0638 and J1823 subject to medical necessity and prior authorization review, and made the listed AIM genetic testing codes subject to prior authorization starting January 1, 2021.
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