MedicaidCoverageMedium impact
Gene Expression Profiling for Cancer Indications - MEDICAID - SOUTH CAROLINA (Revised)
Humana·SC · Oncology, Urology·Medicaid
Effective date
Apr 8, 2026
We identified it
Jun 24, 2026
Summary
Humana South Carolina Medicaid has updated their gene expression profiling policy, providing limited coverage for ConfirmMDx prostate cancer testing under specific clinical conditions while explicitly excluding numerous other gene expression profiling tests. The policy clarifies that most gene expression profiling tests are not covered due to insufficient evidence.
Action Required
Before April 8, 2026: Update billing system to flag South Carolina Medicaid patients for gene expression profiling tests. Configure system to allow CPT 81551 (ConfirmMDx) only for prostate cases with atypia, benign with clinical suspicion, or high-grade PIN. Set all other listed gene expression profiling codes to deny for SC Medicaid. Train billing team on new coverage limitations to prevent claim denials.