MedicaidCoverageMedium impact
Molecular Biomarker Testing for Noncancer Indications - MEDICAID - SOUTH CAROLINA (Revised)
Humana·SC · OB-GYN, Pediatrics, Pathology +1 more·Medicaid
Effective date
Aug 26, 2026
We identified it
Aug 27, 2026
Summary
Humana Medicaid South Carolina updated its molecular biomarker testing policy effective August 26, 2026, establishing coverage criteria for noncancer molecular pathology testing (CPT 81479) and noninvasive prenatal screening (CPT 81509-81512). The policy requires that tests demonstrate analytic validity, clinical validity, and clinical utility supported by peer-reviewed evidence, and that results must change clinical management per specialty society recommendations. EPSDT medical necessity review applies for members under age 21.
Action Required
Before August 26, 2026: (1) Billing team must update billing software to recognize CPT codes 81479, 81509, 81510, 81511, and 81512 as covered under this policy when clinical criteria are met. (2) Configure system to flag requests for members under age 21 for EPSDT medical necessity review before claim submission. (3) Develop internal checklist requiring documentation of: analytic validity, clinical validity, clinical utility (supported by peer-reviewed evidence and specialty society recommendations), and evidence that test results will change clinical management. (4) Train billing and prior authorization staff on coverage criteria—claims lacking documentation of these elements will be denied. (5) Update provider communication materials and encounter forms to clarify that molecular pathology testing requires medical necessity justification tied to specialty society guidelines. (6) OB/GYN and laboratory staff must ensure NIPS requests include maternal age and gestational week information (typically 15-20 weeks) to support medical necessity.