CommercialCoverageMedium impact
Genetic Assay of Tumor Tissue to Determine Prognosis and Treatment of Breast Cancer 2.02.27
Excellus BlueCross BlueShield·Oncology, General Surgery·Genetic Disease (Inherited Disease)
Effective date
Apr 16, 2026
We identified it
Jun 20, 2026
Summary
Excellus BlueCross BlueShield updated their policy for genetic assays of tumor tissue in breast cancer patients, specifying when tests like Oncotype Dx and MammaPrint are considered medically appropriate. The policy establishes specific criteria including tumor characteristics, staging requirements, and a 6-month ordering window after diagnosis.
Action Required
Before April 16, 2026: Billing team must review current breast cancer genetic testing claims to ensure they meet the new criteria including unilateral cancer, hormone receptor positive, HER2 negative, specific tumor sizes and staging, and 6-month ordering timeframe. Update prior authorization processes to verify these requirements. Educate oncology providers on the specific criteria for covered assays versus investigational tests.