MedicaidCoverageHigh impact
Genomic and Molecular Biomarker Testing for Cancer - MEDICAID - MICHIGAN (New)
Humana·MI · Oncology, Hematology, Pathology·Medicaid
Effective date
Sep 23, 2026
We identified it
Sep 16, 2026
Summary
Humana Medicaid Michigan has issued a new comprehensive policy (HUM-MI-2248-000) effective 09/23/2026 that establishes coverage criteria for genomic and molecular biomarker testing in cancer patients. The policy covers specific gene tests (BTK, CCND1::IGH, CEBPA, IDH1/IDH2, MYD88, NPM1, PIK3CA, PLCG2), multigene panels, liquid biopsies, and molecular pathology assays with defined medical necessity requirements for each test type. Billing teams must implement prior authorization requirements and ensure providers document specific cancer diagnoses and clinical indications matching the policy criteria.
Action Required
By 09/23/2026: Billing team must implement the following: (1) Update billing system to recognize all 19 affected codes (81120, 81121, 81168, 81218, 81233, 81277, 81305, 81309, 81310, 81320, 81449, 81455, 81462, 81463, 81464, 81479, 81599, 0172U, 0239U, 0250U) as requiring prior authorization for Michigan Medicaid claims; (2) Create authorization request templates that require documentation of specific cancer diagnosis, disease stage/status (e.g., metastatic, advanced stage III/IV, progression, relapsed), and treatment rationale matching policy indications (e.g., BTK testing only for CLL/SLL with disease progression, PIK3CA only for HR-positive HER2-negative breast cancer); (3) Train providers and billing staff on the specific clinical criteria for each gene test (documented in the policy's Coverage Determination section) to avoid authorization denials; (4) Update encounter forms and EMR templates to include diagnosis-specific fields for cancer type, stage, prior treatment history, and test medical necessity; (5) Configure system to flag claims lacking required documentation elements. Failure to obtain prior authorization or submit claims without matching clinical criteria will result in claim denials from Humana Medicaid Michigan.