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Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment Decisions (for Kentucky Only)
Act
by Oct 1, 2026
Effective date
Oct 1, 2026
Identified
Sep 2, 2026
Summary
UnitedHealthcare Community Plan of Kentucky (Medicaid) revised its molecular oncology testing policy effective October 1, 2026. Key changes include: (1) clarifying coverage applies only to non-FDA companion diagnostic tests; (2) requiring reference to Kentucky Revised Statutes § 304.17A-263 for medical necessity determination; (3) updating breast cancer Gene Expression Profiling test names (Oncotype DX Breast Recurrence Score®, Prosigna® Breast Cancer Assay); and (4) adding new coverage criteria for blood-based colorectal cancer screening using Shield™ for average-risk individuals aged 45-85 with specific clinical parameters.
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What to do
by Oct 1, 2026 · 5 steps
01Billing and clinical teams must update internal documentation and ordering systems to reference Kentucky Revised Statutes § 304.17A-263 as the primary medical necessity criteria for biomarker/molecular oncology testing for all Medicaid patients.
02Update prior authorization workflows to deny coverage for any molecular oncology tests that have received FDA clearance/approval as companion diagnostics.
03Revise breast cancer GEP test references in billing system and clinical order entry: replace 'Oncotype Dx® Breast' with 'Oncotype DX Breast Recurrence Score®' and 'Prosigna® Breast Cancer Prognostic Gene Signature Assay (PAM 50)' with 'Prosigna® Breast Cancer Assay' to ensure correct test identification for claims.
04Add Shield™ blood-based CRC screening to covered services list with requirement that billing/prior auth staff verify: patient age 45-75 or 76-85 (if never screened and healthy), average CRC risk (no personal/family history of polyps, CRC, IBD, or Lynch syndrome), agreement to follow-up colonoscopy if abnormal, and no current GI symptoms.
05Update prior authorization decision templates and denial reason codes to cite KRS § 304.17A-263 when denying claims.
If missed: Failure to implement these changes will result in claim denials and coverage disputes with Kentucky Medicaid for molecular oncology services.
Original notice
Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment Decisions (for Kentucky Only)
uhcprovider.com · Always check the source before changing claims.