MedicaidCoverageHigh impact
Molecular Biomarker Testing for Noncancer Indications - MEDICAID - VIRGINIA (Revised)
Humana·VA · Cardiology, Nephrology, Gastroenterology +7 more·Medicaid
Effective date
Aug 26, 2026
We identified it
Aug 27, 2026
Summary
Humana Virginia Medicaid revised its molecular biomarker testing policy effective 08/26/2026, establishing coverage criteria for molecular pathology testing (CPT 81479) for noncancer indications when tests demonstrate analytic validity, clinical validity, and clinical utility with evidence of changed clinical management. The policy explicitly denies coverage for gene expression profiling (GEP) for all noncancer indications, including psychiatric conditions, pain management, longevity prediction, and pulmonary diseases. New coverage for CSF biomarker testing (CPT 0358U) for Alzheimer's disease is permitted when patients are considered for FDA-approved monoclonal antibody therapy.
Action Required
Before August 26, 2026: Billing team must implement the following changes in the Virginia Medicaid billing system: (1) Configure CPT 81479 (molecular pathology) to require documentation of analytic validity, clinical validity, clinical utility, and evidence that results will change clinical management before claim submission; (2) Add CPT 0358U (CSF biomarker testing for Alzheimer's disease) as covered only when patient is being evaluated for FDA-approved monoclonal antibody therapy (lecanemab-irmb [Leqembi] or donanemab-azbt [Kisunla]); (3) Block all billing for gene expression profiling (GEP) tests for noncancer indications including but not limited to MindX Pain, MindX Mood, Envisia Genomic Classifier, Igenomix Endometrial Receptivity Analysis, and all psychiatric/behavioral GEP tests - these will be denied as non-covered services; (4) For members under age 21, flag all molecular biomarker testing requests for medical necessity review per EPSDT requirements. Update prior authorization templates and denial messaging accordingly. Claims submitted without proper supporting documentation or for non-covered GEP tests will be denied. Notify providers in Virginia Medicaid network of coverage restrictions, particularly psychiatry, pain management, and fertility specialists.