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Gene Expression Profiling for Noncancer Indications - Medicare Advantage (Revised)
Effective date
Aug 3, 2026
Identified
Aug 4, 2026
Summary
Humana Medicare Advantage updated its coverage policy for Gene Expression Profiling (GEP) tests used for noncancer indications, effective August 3, 2026. The policy establishes medical necessity criteria for GEP tests including Envisia Genomic Classifier for idiopathic pulmonary fibrosis and EpiSign Complete for epigenetic/imprinting disorders, requiring tests to be MolDX-approved, FDA-cleared, or meet clinical utility standards where CMS guidance is lacking. Billing teams must ensure claims align with jurisdiction-specific LCD requirements and document that test results directly impact patient treatment decisions.
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What to do
Action · 6 steps
01Before August 3, 2026: Billing team must verify coverage criteria for gene expression profiling claims in your jurisdiction by consulting the applicable MAC LCD (L37919, L37905, L37887, L37891, L37857, or L35000 depending on state).
02Update prior authorization protocols to require: (1) confirmation that the test is MolDX Program approved, FDA approved/cleared, or meets clinical utility standards; (2) documentation that the patient matches the population/indication for which the test was developed; and (3) clinical notes showing results will directly impact treatment/management decisions.
03Providers must document medical necessity on requisition forms.
04Update billing software rules to deny claims lacking required clinical documentation.
05For jurisdictions with established LCDs, follow those specific criteria.
06For jurisdictions without LCDs (J6/JK, JH/JL, JN), apply Humana's general criteria referenced in this policy.
Codes mentioned
81554
Original notice
Gene Expression Profiling for Noncancer Indications - Medicare Advantage (Revised)
mcp.humana.com · Always check the source before changing claims.
Related changes
See all Humana changes →Molecular Biomarker Testing for Noncancer Indications - MEDICAID - KENTUCKY (Revised)HighEffective Sep 23, 2026 · MedicaidGene Expression Profiling for Noncancer Indications - Medicare Advantage (Revised)MediumEffective Nov 3, 2025 · Medicare AdvantageGene Expression Profiling for Cancer Indications - Medicare Advantage (Revised)MediumEffective May 1, 2026 · Medicare AdvantageBrowse every Humana change in the policy list