Medicare AdvantageCoverageHigh impact
Gene Expression Profiling for Cancer Indications - Medicare Advantage (Revised)
Humana·Oncology, Pathology, General Surgery +1 more·Medicare Advantage
Effective date
May 1, 2026
We identified it
Sep 4, 2026
Summary
This is a revised Medicare Advantage policy (HUM-1092-015) governing coverage for Gene Expression Profiling tests used in cancer diagnosis and risk stratification. The policy became effective 05/01/2026 and consolidates coverage rules across multiple cancer types (breast, prostate, lung, bladder, melanoma, colon) with jurisdiction-specific LCD requirements based on MAC contractors. The policy references multiple MolDX and molecular testing LCDs that billing teams must follow by geographic region.
Action Required
By May 1, 2026: Billing team must identify which Medicare Advantage patients are located in each MAC jurisdiction (J5, J8, J6, JK, J15, JE, JF, JH, JL, JJ, JM) and implement the corresponding LCD requirements for gene expression profiling claims. Update billing system to apply the correct LCD rules by geographic location before processing any claims for these tests. Reference the specific LCD document numbers listed in the policy (e.g., L36811, A57560 for Wisconsin; L35000, A56199 for Illinois/Minnesota/Wisconsin) when validating medical necessity and prior authorization requirements. Failure to apply the correct MAC-specific LCD will result in claim denials. Providers should update ordering workflows to ensure tests ordered align with the applicable LCD in the patient's geographic region.