All PlansPrior AuthMedium impact
Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes
Regence BlueShield·Oncology, Gastroenterology, OB-GYN +2 more·Prior Authorization
Effective date
Feb 1, 2026
We identified it
Jun 16, 2026
Summary
New prior authorization policy for genetic testing related to Lynch syndrome and polyposis syndromes (APC, MUTYH, MMR genes) effective February 1, 2026. Specific medical necessity criteria must be met including family history requirements, cancer diagnoses, or risk prediction model scores of 5% or higher.
Action Required
Before February 1, 2026: Billing team must implement prior authorization requirements for genetic testing of APC, MUTYH, MLH1, MSH2, MSH6, PMS2, and EPCAM genes. Update system to require documentation of medical necessity criteria including family history, cancer diagnoses, or risk prediction scores. Ensure providers document required information: test names, laboratory, specific genes tested, billing codes, clinical decision rationale, and medical records. Claims without proper authorization and documentation will be denied.