CPT 81518 is referenced in 8 tracked payer policy changes from Blue Cross Blue Shield of Rhode Island, Blue Shield of California, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 81518 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Multiple medical policies are being updated with changes to prior authorization requirements, covered diagnosis codes, and billing procedures across various specialties. Key changes include removal of prior authorization for several CPT codes, addition of new ICD-10 codes for breast cancer-related services, and updates to genetic testing coverage criteria.
Effective July 1, 2025, clarifications for provider specialties were made to the outpatient professional behavioral health services policy for Medicare Advantage plans and commercial products. Effective September 1, 2025, transcranial magnetic stimulation (TMS) coverage changes from covered to covered only when filed with a covered ICD-10 code for the CPT codes in the TMS policy, for Medicare Advantage plans and commercial products. Effective September 1, 2025, prior authorization is removed for several genetic testing codes, and other codes move their medical criteria to the online authorization tool.
Blue Shield of California medical policy 2.04.36, on assays of genetic expression in tumor tissue to determine prognosis in patients with breast cancer, has an effective date of November 1, 2026. The policy history lists that date as an annual review in which the policy statement and literature were updated. The policy addresses Oncotype DX, EndoPredict, Breast Cancer Index, MammaPrint and Prosigna, lists the criteria under which these tests may be considered medically necessary for adjuvant chemotherapy decisions, and states that all other indications are investigational.
Texas Medicaid is adding new genetic testing benefits effective May 1, 2026, including whole exome sequencing, FoundationOne cancer testing, transplant rejection monitoring, ClonoSEQ testing for blood cancers, enhanced liver fibrosis testing, and breast cancer index testing. All these new tests require prior authorization and have specific medical necessity criteria and frequency limitations.
Excellus BlueCross BlueShield medical policy 2.02.27 has a current effective date of April 16, 2026. Oncotype Dx Breast Recurrence Score and the MammaPrint 70-gene panel are considered medically appropriate to guide the decision about adjuvant chemotherapy for newly diagnosed breast cancer when all listed criteria are met, including unilateral disease, hormone receptor positive and HER2 negative status, Stage 1 or Stage 2 disease, three or fewer positive axillary nodes, no distant metastasis, and an assay ordered within six months after diagnosis. Breast Cancer Index, Prosigna and EndoPredict are considered medically appropriate under separate criteria for axillary lymph node-negative disease. All other gene expression classifiers, such as Oncotype DX Breast DCIS Score, DCISionRT, AidaBreast and PreciseDx, are considered investigational for breast cancer. The 2026 annual review made no change to policy intent and added PLA code 0630U.
The Blue Cross Blue Shield Association policy on gene expression assays in breast cancer (Oncotype DX, EndoPredict, Breast Cancer Index, MammaPrint and Prosigna) now states that a gene expression assay during workup for women considering preoperative (neoadjuvant) therapy is investigational. A policy update dated 08/25/2026 also changed the title to include predicting therapeutic response and updated the guidance on omitting sentinel lymph node biopsy and neoadjuvant therapy. The assays may be considered medically necessary for the listed node-negative and node-positive criteria, and are investigational for all other indications, including repeat testing, combination testing and length of endocrine therapy.
NYS Medicaid fee-for-service and Medicaid Managed Care cover breast cancer screening and diagnostic imaging with no cost-sharing to the patient, as the New York State Breast Cancer Screening Law requires. Coverage includes diagnostic mammograms, breast ultrasound, and MRI when ordered by a provider in accordance with nationally recognized clinical guidelines. Mammography alone is the recommended and preferred screening modality for most people, and MRI should not replace mammography. Coverage criteria also apply to tomosynthesis, breast biopsy, BRCA1 and BRCA2 testing, and predictive and prognostic breast cancer assays.
Effective April 1, 2019, the provider taxonomy code must be submitted on all claims. Reported as already effective in the historical source, Medicare Advantage claims for out-of-network payments require the Health Trio referral number in box 23 of the CMS-1500 form. January 2019 CPT and HCPCS code changes are effective January 1, 2019, and the code lists carry coverage designations such as Subject to Medical Review, Not Medically Necessary, Not Separately Reimbursed and Not Covered.
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