MedicaidCoverageHigh impact
Expanded Coverage of Cancer Biomarkers for Companion Diagnostic Testing and Targeted Drug Therapies, Effective August 1, 2023
Maryland Medicaid·MD · Oncology, Radiation Oncology, Pathology·Provider Transmittal
Effective date
Aug 1, 2023
We identified it
Jun 20, 2026
Summary
Maryland Medicaid expanded coverage for 21 cancer biomarker companion diagnostic tests effective August 1, 2023. The policy adds specific CPT and HCPCS codes to the Medicaid fee schedule with defined reimbursement rates. Most tests require prior authorization; MCOs must contract with proprietary test vendors and may establish their own preauthorization requirements.
Action Required
By August 1, 2023: Billing team must update systems to recognize and bill the 23 cancer biomarker CPT/HCPCS codes listed in the transmittal. Verify that contracted laboratory vendors are enrolled in Maryland Medicaid. Configure billing software to require prior authorization for all codes except 0155U, 0177U, 81235, 81210, 0111U, 0154U, 81120, and 0023U (which do not require pre-auth). Update fee schedules to reflect the specific reimbursement rates provided (ranging from $139.44 to $6,721.70). Notify ordering providers about the new covered tests and preauthorization requirements. Establish internal workflows to route prior authorization requests to the appropriate MCO contacts. Failure to implement prior authorization where required will result in claim denials.