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UnitedHealthcareMedicaid · Coverage · Medical Policy · NC · Oncology, Pathology, EndocrinologyHigh impact

Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment Decisions (for North Carolina Only)

Act
by Nov 30, 2026
Effective date
Dec 1, 2026
Identified
Sep 2, 2026

Summary

UnitedHealthcare Community Plan of North Carolina (Medicaid) has issued a new policy effective December 1, 2026, that restricts coverage of molecular oncology testing for solid tumors to only FDA-cleared/approved companion diagnostics and specific approved tests (lung cancer multigene panels ≤50 genes, anaplastic thyroid cancer comprehensive genomic profiling, and indeterminate thyroid nodule testing). All other molecular tests including NGS panels, cancer genomic profiling, and multicancer screening tests are now classified as unproven and non-medically necessary, requiring denial or prior authorization review.

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What to do

by Nov 30, 2026 · 5 steps
01Billing team must update claim processing system to automatically flag and require prior authorization for all molecular oncology testing claims for solid tumors submitted under NC Medicaid.
02Create a claims denial protocol for unproven tests listed in the policy (OncoDEEP, Oncotype DX Breast DCIS Score, BluePrint, DecisionDx-Melanoma, Galleri, Signatera, Tempus xE/xR, and all others specified).
03Providers must be notified through bulletin distribution and training that only three categories are covered: multigene lung cancer panels (≤50 genes), anaplastic thyroid cancer genomic profiling, and indeterminate thyroid nodule molecular testing (when meeting Bethesda III/IV and surgical decision criteria).
04Update encounter forms and provider ordering systems to display approved vs. unproven test categories.
05Implement compliance checks to reference NC Medicaid Clinical Coverage Policy 1S-11 for genetic testing requirements.
If missed: Failure to implement will result in claim denials and member appeals.

Original notice

Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment Decisions (for North Carolina Only)
uhcprovider.com · Always check the source before changing claims.
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