Who is affected by this change?

This affects Excellus BlueCross BlueShield Oncology, Urology, Pathology providers in NY on Commercial, Medicare Advantage, Medicaid plans.

When does this change take effect?

This change is effective Sep 17, 2026.

What do I need to do?

Already effective September 17, 2026: Biomarker tests for prostate cancer that diagnose or determine a risk score are considered investigational, and the codes marked (E/I) in the policy are Experimental/Investigational. Gene expression analysis to guide management of prostate cancer is considered medically appropriate only when ALL of these criteria are met: it is done during initial risk stratification, the individual has a life expectancy of ten or more years, and the individual falls into a listed disease risk group. For Oncotype DX Genomic Prostate Score (GPS) or ProMark, the listed groups are low-risk disease or favorable intermediate-risk disease. For Prolaris or Decipher, the listed groups are low-risk, favorable intermediate, unfavorable intermediate or high-risk disease. ArteraAI is considered investigational for the management of prostate cancer. Codes may not be covered under all circumstances, and the code list may not be all inclusive. Genetic testing is appropriate only when performed by a qualified laboratory certified under CLIA and offered in a setting with adequately trained health care professionals who are qualified to provide pre- and post-test counseling. Genetic testing is contract dependent, so coverage applies only to members with a valid contract and is not provided for family members without a valid contract.

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Excellus BlueCross BlueShieldCommercial · Coverage · Genetic Disease (Inherited Disease) · NY · Oncology, Urology, PathologyMedium impact

Laboratory Testing for the Screening and Management of Prostate Cancer 2.02.48

Q: Which billing codes are affected?

The following codes are affected: 81313, 81539, 81541, 81542, 81551, 81479, C61, D07.5, D29.1, D40.0, N42.30, N42.31, N42.32, N42.39, R97.20, R97.21, Z12.5, Z85.46.

Effective date

Sep 17, 2026

Identified

Jun 20, 2026

Summary

Excellus BlueCross BlueShield policy 2.02.48 considers biomarker tests for prostate cancer that diagnose or determine a risk score investigational, including PROGENSA PCA3, 4Kscore, Prostate Health Index and ConfirmMDx. Gene expression analysis to guide management of prostate cancer is considered medically appropriate only under the listed criteria, and ArteraAI is considered investigational for management of prostate cancer. The current version is effective September 17, 2026, and its most recent change is an annual review with the policy intent unchanged.

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What to do

Action · 8 steps

01Already effective September 17, 2026: Biomarker tests for prostate cancer that diagnose or determine a risk score are considered investigational, and the codes marked (E/I) in the policy are Experimental/Investigational.

02Gene expression analysis to guide management of prostate cancer is considered medically appropriate only when ALL of these criteria are met: it is done during initial risk stratification, the individual has a life expectancy of ten or more years, and the individual falls into a listed disease risk group.

03For Oncotype DX Genomic Prostate Score (GPS) or ProMark, the listed groups are low-risk disease or favorable intermediate-risk disease.

04For Prolaris or Decipher, the listed groups are low-risk, favorable intermediate, unfavorable intermediate or high-risk disease.

05ArteraAI is considered investigational for the management of prostate cancer.

06Codes may not be covered under all circumstances, and the code list may not be all inclusive.

07Genetic testing is appropriate only when performed by a qualified laboratory certified under CLIA and offered in a setting with adequately trained health care professionals who are qualified to provide pre- and post-test counseling.

08Genetic testing is contract dependent, so coverage applies only to members with a valid contract and is not provided for family members without a valid contract.

Codes mentioned

813138153981541815428155181479C61D07.5D29.1D40.0N42.30N42.31N42.32N42.39R97.20R97.21Z12.5Z85.46

Original notice

Laboratory Testing for the Screening and Management of Prostate Cancer 2.02.48

excellusbcbs.com · Always check the source before changing claims.

View original ↗

Magnetic Resonance Imaging (MRI) of the Prostate - (Effective Date - 2026-10-15) 6.01.46HighEffective Oct 15, 2026 · Radiology (x-rays) & Imaging Germline Genetic Testing for Hereditary Cancers 2.02.60MediumEffective Apr 16, 2026 · Genetic Disease (Inherited Disease)Focal Therapies for Prostate Cancer Treatment 7.01.01MediumEffective Aug 20, 2026 · Urinary System (Genitourinary)Radiopharmaceuticals for the Treatment of Cancer 6.01.44MediumEffective Sep 17, 2026 · Cancer Treatment (Oncology)Browse every Excellus BlueCross BlueShield change in the policy list

Laboratory Testing for the Screening and Management of Prostate Cancer 2.02.48

Summary

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What to do

Codes mentioned

Original notice

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