Medicare AdvantageCoverageHigh impact
Molecular Markers in Fine Needle Aspirates of Thyroid Nodules - Medicare Advantage (Revised)
Humana·Endocrinology, Pathology, Oncology +1 more·Medicare Advantage
Effective date
Sep 10, 2026
We identified it
Sep 11, 2026
Summary
This revised Medicare Advantage policy (effective 09/10/2026) establishes coverage criteria for molecular marker testing in fine needle aspirates of thyroid nodules, including Afirma GSC, ThyGeNext/ThyraMIRv2, and ThyroSeq v3 GC tests. Coverage is determined by applicable MAC Local Coverage Determinations (LCDs) in each jurisdiction, with specific criteria varying by geographic region and test type.
Action Required
By September 10, 2026: Billing team must update authorization protocols and billing system rules to implement jurisdiction-specific LCD requirements for thyroid nodule molecular testing. (1) Map each practice location to its applicable MAC jurisdiction (J5/J8, J6/JK, J15, JE/JF, JH/JL, JJ/JM, or JN) using the CMS jurisdiction table provided in the policy. (2) For each jurisdiction, retrieve and integrate the applicable LCD(s) from the Related CMS Documents section—particularly L39682 (MolDX thyroid testing), L35396 (Biomarkers for Oncology), or L38968 (Thyroid Nodule Molecular Testing). (3) Update prior authorization requirements in billing software to reflect jurisdiction-specific medical necessity criteria for CPT 81546 (Afirma GSC), CPT 0245U (ThyGeNext), CPT 0018U/81599 (ThyraMIRv2), and CPT 0026U (ThyroSeq v3 GC). (4) Ensure providers document that tests are ordered by treating physicians for beneficiary management of specific thyroid nodule cases and that specimens are from fine needle aspirates. (5) Train billing and prior authorization staff on jurisdiction-specific rules, particularly for multiple thyroid nodule testing variations noted in the policy. Failure to apply correct jurisdiction-specific LCDs will result in claim denials for non-compliant requests.