MedicaidCoverageHigh impact
Genomic and Molecular Biomarker Testing for Cancer - MEDICAID - INDIANA (Revised)
Humana·IN · Oncology, Hematology, Endocrinology +1 more·Medicaid
Effective date
Sep 23, 2026
We identified it
Sep 15, 2026
Summary
Humana Indiana Medicaid updated its coverage policy for genomic and molecular biomarker testing for cancer, effective 09/23/2026. The policy specifies coverage criteria for multigene panel testing (CPT 81449), NPM1 gene testing (CPT 81310), molecular pathology testing (CPT 81479), and ThyroSeq v3 Genomic Classifier (CPT 0026U), while explicitly denying coverage for ThyroSeq v3 Cancer Risk Classifier (CPT 0287U) and multiple molecular marker assays for thyroid nodules. Billing teams must ensure claims align with the documented medical necessity criteria for each test type.
Action Required
By September 23, 2026: Billing team must implement the following in billing system and claim submission workflows: (1) For CPT 81449 (multigene panel testing for solid tumors), require documentation that patient has diagnosed recurrent, relapsed, refractory, metastatic, or advanced stage III/IV cancer AND has decided to seek further cancer treatment before approving claims; (2) For CPT 81310 (NPM1 gene testing), verify indication is limited to AML, APL, MDS, MPNs, or suspected myeloid malignancy with undefined cytopenia; (3) For CPT 81479 (molecular pathology testing), require documentation of analytic validity, clinical validity, clinical utility supported by peer-reviewed evidence, and that results will change clinical management per specialty society recommendations; (4) For CPT 0026U (ThyroSeq v3 Genomic Classifier), restrict to indeterminate thyroid FNA cytopathology only (Bethesda III or IV categories) and deny claims with multiple molecular marker assays; (5) DENY all claims for CPT 0287U (ThyroSeq v3 Cancer Risk Classifier) as non-covered service. For members under 21, ensure all requests are reviewed for EPSDT medical necessity compliance. Update prior authorization rules, denial templates, and provider education materials. Failure to implement these restrictions will result in improper claim payments and potential audit exposure.