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Gene Expression Profiling for Cancer Indications - MEDICAID - VIRGINIA (Revised)
Effective date
Oct 14, 2026
Identified
Oct 7, 2026
Summary
Humana Medicaid Virginia revised its Gene Expression Profiling (GEP) coverage policy effective 2026-10-14, maintaining coverage for specific tests (Cxbladder Triage, ConfirmMDx, and molecular pathology/MAAA tests meeting clinical criteria) while continuing to exclude 19 named GEP tests due to insufficient evidence. Billing teams must verify which GEP tests are ordered against the coverage lists and enforce prior authorization requirements based on clinical criteria.
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What to do
Action · 5 steps
01Effective 2026-10-14: Billing team must update prior authorization protocols and claim submission rules in the billing system to distinguish covered versus non-covered GEP tests for Virginia Medicaid members.
02For covered tests—Cxbladder Triage (0363U), ConfirmMDx (81551), and molecular pathology/MAAA tests (81479, 81599)—implement prior authorization requiring verification of clinical criteria (analytic/clinical validity and utility supported by peer-reviewed evidence, clinical utility that changes management per specialty guidelines).
03For 19 non-covered tests (BluePrint 0630U, Cxbladder Detect/Monitor/Triage Plus 0012M/0013M/0420U, DecisionDx-SCC 0315U, EarlyTect BCD 0452U, Merlin 0578U, PancreaSeq 0313U, PROSTOX 0534U, PurIST 0510U, BBDRisk Dx IHC 0067U, CancerDetect 0296U, Darwin OncoTarget/OncoTreat 0019U, Decipher Bladder TURBT 0016M, DetermaRx 0288U, Insight TNBCtype 0153U, Lymph2Cx/3Cx 0017M/0120U, miR-31now 0069U, OncoSignal-7 0262U)—configure system to automatically deny or require medical director review with evidence of medical necessity.
04Providers should be notified of coverage restrictions to prevent inappropriate ordering.
05Members under age 21 require additional EPSDT medical necessity review.
If missed: Failure to apply correct coverage determinations will result in claim denials or member balance billing liability.
Codes mentioned
814798155181599
Original notice
Gene Expression Profiling for Cancer Indications - MEDICAID - VIRGINIA (Revised)
mcp.humana.com · Always check the source before changing claims.
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