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Gene Expression Profiling for Cancer Indications - Medicare Advantage (Revised)
Act
by Sep 30, 2026
Effective date
Oct 1, 2026
Identified
Sep 29, 2026
Summary
This is a comprehensive Medicare Advantage policy update (Policy HUM-1092-016) governing coverage and billing for gene expression profiling tests across multiple cancer indications, including breast, colon, prostate, lung, and melanoma. The policy became effective October 1, 2026, and consolidates MolDX (Molecular Diagnostics) LCD requirements across all Medicare Administrative Contractor (MAC) jurisdictions nationwide. Billing teams must ensure claims for genetic cancer tests comply with the specific MAC jurisdiction requirements and applicable CPT/HCPCS codes listed in the policy.
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What to do
by Sep 30, 2026 · 7 steps
01Billing team must review the complete policy document (pages 1-41, not fully provided here) to identify all specific CPT and HCPCS codes applicable to your geographic MAC jurisdiction.
02Update billing system rules and denial prevention logic to enforce prior authorization requirements and coding guidelines for gene expression profiling tests (Prosigna, Oncotype DX, MammaPrint, EndoPredict, BluePrint, Cancer TYPE ID, and other MolDX tests).
03Identify which MAC services your practice (based on provider location and patient residence) and cross-reference applicable LCDs from the policy.
04Add clinical documentation requirements and medical necessity criteria to EMR templates for oncology providers.
05Train billing staff on jurisdiction-specific coding rules (note: policies vary by MAC—J5, J8, J6, JK, J15, JE, JF, JH, JL, JJ, JM).
06Claims submitted without compliance will face denials.
07Ensure providers understand that gene expression testing requires documentation of medical necessity aligned with MolDX coverage criteria.
Original notice
Gene Expression Profiling for Cancer Indications - Medicare Advantage (Revised)
mcp.humana.com · Always check the source before changing claims.
Related changes
See all Humana changes →Gene Expression Profiling for Cancer Indications - Medicare Advantage (Revised)MediumEffective Oct 12, 2026 · Medicare AdvantageGene Expression Profiling for Cancer Indications - Medicare Advantage (Revised)MediumEffective May 1, 2026 · Medicare AdvantageBrowse every Humana change in the policy list