Traditional MedicareCoverageHigh impact
MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Targeted Therapy in Cancer
Medicare/CMS - LCD·Oncology, Pathology·Local Coverage Determination
Effective date
Oct 12, 2026
We identified it
Aug 27, 2026
Summary
CGS Administrators, LLC has issued a new Local Coverage Determination (LCD L40226) effective 10/12/2026 establishing coverage policies for non-Next Generation Sequencing targeted molecular panel tests used for targeted cancer therapy. This policy defines medical necessity criteria, covered indications, and billing requirements for these molecular diagnostic tests under Medicare Part A and Part B. Billing teams must review this policy to ensure compliant coding and documentation practices for cancer molecular testing claims.
Action Required
Before 10/12/2026: (1) Billing team must obtain and review the complete LCD L40226 policy text from https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=40226&ver=4 to identify specific CPT/HCPCS codes affected. (2) Oncology and pathology staff must document all medical necessity requirements specified in the policy for molecular panel testing. (3) Update billing system rules to enforce coverage criteria and identify any tests that moved from covered to non-covered or vice versa. (4) Train billing and clinical staff on new documentation requirements before the effective date. (5) Update encounter templates and order forms to capture required clinical information per policy guidelines. Claims submitted after 10/12/2026 without proper coverage documentation and coding per this LCD will be subject to denial by CGS.