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Genetic Testing for Hereditary Breast, Ovarian, Pancreatic and Prostate Cancer - Medicare Advantage (Revised)
Act
by Aug 3, 2026
Effective date
Aug 3, 2026
Identified
Aug 4, 2026
Summary
Humana Medicare Advantage has updated its genetic testing policy for hereditary breast, ovarian, pancreatic, and prostate cancer effective 08/03/2026. The policy establishes coverage criteria for germline multigene panel testing, known familial variant testing, and related conditions (Li-Fraumeni syndrome, PTEN hamartoma tumor syndrome/Cowden syndrome), with coverage determination based on CMS NCDs/LCDs, MolDX registry evaluation, or Humana's medical necessity criteria when CMS guidance is absent.
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What to do
by Aug 3, 2026 · 6 steps
01Billing and clinical teams must implement the updated genetic testing coverage policy for Medicare Advantage beneficiaries.
02Billing team: Update prior authorization templates and claims submission systems to reflect new coverage criteria for multigene panel testing (hereditary breast, ovarian, pancreatic, prostate cancer), known familial variant testing, Li-Fraumeni syndrome, and PTEN hamartoma tumor syndrome/Cowden syndrome testing.
03Provider/ordering physicians: Ensure test orders include appropriate medical necessity documentation per policy requirements before submission.
04Prior authorization staff: Familiarize with jurisdiction-specific MACs and their applicable LCDs (J5, J8, J6, JK, J15, JE, JF, JH, JL, JJ, JM, JN) as coverage varies by geographic location.
05Claims processing: Route claims through jurisdiction-specific MACs using their designated LCDs (e.g., MolDX LDT criteria for inherited cancer syndromes).
06For jurisdictions without CMS guidance (J6/JK, JH/JL, JN), apply LCD L38972 criteria.
If missed: Failure to align with updated policy will result in claim denials and rework.
Original notice
Genetic Testing for Hereditary Breast, Ovarian, Pancreatic and Prostate Cancer - Medicare Advantage (Revised)
mcp.humana.com · Always check the source before changing claims.
Related changes
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