UnitedHealthcare · Effective Jan 1, 2027Medium impact
Molecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment Decisions (for New Mexico Only)
UnitedHealthcare Community Plan of New Mexico revised its Molecular Oncology Testing for Hematologic Cancer policy, effective 2027-01-01, for New Mexico Medicaid members. Multigene panels of up to 50 genes are covered when performed at initial diagnosis or relapse, ordered by a hematologist or oncologist, and intended for listed conditions; clonoSEQ is covered for clonality and measurable residual disease testing, and several other molecular oncology tests (including EpiSwitch Checkpoint Inhibitor Response Test, optical genome mapping and whole-transcriptome sequencing) are deemed unproven. Billing teams should confirm test ordering, diagnosis documentation, and CPT coding on molecular oncology claims for these members before the effective date.
By 2027-01-01: Billing team should update charge entry and claim edits for molecular oncology orders so that claims for CPT codes 0332U, 0592U, 0644U and 0645U, and removed codes 0485U, 0560U and 0561U, are coded to the revised criteria, and ensure ordering provider specialty (hematology or oncology) and the diagnosis and treatment-stage documentation are captured on the requisition for New Mexico Medicaid members. Providers and front desk staff should be told that unproven tests listed in the policy are not covered for these members and that orders for those tests should be reviewed before collection.