MedicaidCoverageMedium impact
Genomic and Molecular Biomarker Testing for Cancer - MEDICAID - FLORIDA (Revised)
Humana·FL · Hematology, Oncology, Pathology·Medicaid
Effective date
Sep 16, 2026
We identified it
Sep 15, 2026
Summary
Humana Florida Medicaid has released a revised policy (effective 09/16/2026) establishing coverage criteria for genomic and molecular biomarker testing in cancer patients. The policy specifies which hematologic malignancies, myeloid disorders, and solid tumors qualify for comprehensive genomic profiling (CGP) or single-gene testing, with strict limitations on eligible diagnoses. Billing teams must ensure claims for CPT codes 81450 and 81455 include documented medical necessity matching one of five defined indications.
Action Required
Before September 16, 2026: Billing team must update authorization and claims submission workflows to enforce coverage criteria for CPT 81450 and 81455 under Florida Medicaid. Specifically: (1) Require providers to document ONE of the five eligible indications—AML, MDS, MPN (PV/ET/PMF), suspected myeloid malignancy with undefined cytopenia >4 months, or systemic mastocytosis—on all genomic testing requests; (2) Configure billing system to deny or hold claims that lack supporting diagnosis codes matching these criteria; (3) Update prior authorization templates to mandate indication verification before approval; (4) Train front-desk and billing staff to flag requests without compliant documentation. For members under 21, ensure EPSDT medical necessity review is performed. Claims submitted without documented eligible indications will be denied by Humana.