CPT 81552 is referenced in 3 tracked payer policy changes from Humana and Blue Cross & Blue Shield of Mississippi. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 81552 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
New Ohio Medicaid policy establishes coverage for specific gene expression profiling tests for cancer, covering ConfirmMDx for prostate cancer management and DecisionDx-UM for uveal melanoma risk stratification, while explicitly excluding three other GEP tests due to insufficient evidence.
Gene expression profiling for uveal melanoma with DecisionDx-UM is medically necessary for individuals with primary, localized uveal melanoma. Gene expression profiling for uveal melanoma that does not meet that criterion is investigational. To date, the U.S. Food and Drug Administration has chosen not to require any regulatory review of this test.
Genetic testing is considered medically necessary to establish a molecular diagnosis of an inheritable disease when the member displays clinical features or is at direct risk of inheriting the mutation in question, the result of the test will directly impact the treatment being delivered to the member, and a definitive diagnosis remains uncertain after history, physical examination, and completion of conventional diagnostic studies. Section I lists inheritable diseases for which genetic testing is medically necessary when these criteria are met, and Section II lists specific tests, including BRCAnalysis, Breast Cancer Index, Cologuard, and Alzheimer's disease testing, that are medically necessary when their own criteria are met. Section III lists tests considered investigational for conditions such as arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C), Parkinson's disease, and migrainous vertigo. Section IV states that any genetic test not listed as medically necessary in Sections I or II is investigational, and that any home genetic test is investigational.
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