81535 Insurance Policy Changes

CPT 81535 is referenced in 10 tracked payer policy changes from Aetna and Humana. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 81535 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

High impact
Tumor Chemosensitivity Assays (CPB 0245, reviewed 2026-04-13)
Aetna·Effective Apr 13, 2026
Aetna is maintaining a non-coverage stance on tumor chemosensitivity assays, classifying them as experimental/investigational/unproven. This policy (CPB 0245, reviewed 2026-04-13) specifies 15+ assay types and their associated CPT codes that will not be covered, including 3D Predict assays, ChemoFx, MiCK apoptosis assay, and others. Billing teams must ensure claims for these assays are not submitted or are denied appropriately, and providers must be aware these services are patient-responsibility.
Medium impact
Pharmacogenomics Testing - MEDICAID - VIRGINIA (Revised)
Humana·Effective Jul 22, 2026
Humana Medicaid (Virginia) has revised its pharmacogenomics testing coverage policy effective 07/22/2026. The policy now covers molecular pathology testing (CPT 81479) for pharmacogenomics analysis when patients are being treated with or considered for medications with known FDA-labeled or CPIC guideline level A/B gene-drug interactions. A specific list of 17 branded pharmacogenomics tests are explicitly non-covered due to insufficient evidence.
Medium impact
Pharmacogenomics Testing - MEDICAID - SOUTH CAROLINA (Revised)
Humana·Effective Jul 22, 2026
Humana Medicaid in South Carolina updated its pharmacogenomics testing coverage policy, effective July 22, 2026. The policy now covers ChemoFx Assay (CPT 81535/81536) for gynecologic cancers meeting specific clinical criteria, and molecular pathology testing (CPT 81479) for patients on medications with FDA-labeled or CPIC Level A/B gene-drug interactions. For members under 21, all requests require medical necessity review under EPSDT requirements.
Medium impact
Pharmacogenomics Testing - MEDICAID - MICHIGAN (New)
Humana·Effective Jul 22, 2026
Humana Michigan Medicaid now covers pharmacogenomics testing (CPT 81479) for patients on medications with known gene-drug interactions per FDA labeling or CPIC guidelines (level A or B). However, ChemoFx Assay (CPT 81535/81536) and SLCO1B1 genotype testing (CPT 81328) are explicitly NOT covered due to insufficient evidence. Billing teams must verify drug-gene interaction documentation before submitting claims and deny or reject claims for the two excluded test codes.
Medium impact
Pharmacogenomics Testing - MEDICAID - INDIANA (New)
Humana·Effective Apr 8, 2026
Humana Indiana Medicaid has established a new comprehensive pharmacogenomics testing policy effective April 8, 2026, specifying which genetic tests are covered versus not covered. The policy covers specific tests like DPYD, GeneSight Psychotropic, NUDT15/TPMT, SLCO1B1, and TYMS genotype testing under defined clinical criteria, while explicitly excluding many comprehensive panels and other pharmacogenomic tests.
Medium impact
Pharmacogenomics Testing - MEDICAID - KENTUCKY (New)
Humana·Effective Nov 12, 2025
Humana Kentucky Medicaid has established a new pharmacogenomics testing policy effective November 12, 2025. The policy covers only DPYD genotype testing (81232) and NUDT15/TPMT genotype testing (81306, 84433) for specific medication dosing guidance, while explicitly excluding coverage for all other pharmacogenomic tests including comprehensive panels and behavioral health genetic testing.
Medium impact
Pharmacogenomics Testing - MEDICAID - OHIO (New)
Humana·Effective Jun 25, 2025
Humana Ohio Medicaid now covers specific pharmacogenomics tests (DPYD, NUDT15, TPMT) for guiding medication dosing or managing severe toxicity, while explicitly excluding numerous other genetic testing panels. This is a new policy establishing clear coverage criteria for genetic testing to optimize medication therapy.
Medium impact
Pharmacogenomics Testing - MEDICAID - VIRGINIA (Revised)
Humana·Effective Apr 1, 2025
Humana Virginia Medicaid updated their pharmacogenomics testing policy, covering only DPYD, NUDT15, and TPMT genetic tests for specific medication dosing guidance, while excluding all other pharmacogenomic tests including behavioral health panels and comprehensive testing. Most pharmacogenomic tests will not be covered due to insufficient evidence.
Medium impact
Pharmacogenomics Testing - MEDICAID - SOUTH CAROLINA (Revised)
Humana·Effective Apr 1, 2025
Humana Medicaid South Carolina has updated their pharmacogenomics testing policy, defining specific coverage for DPYD and NUDT15/TPMT genetic tests while explicitly excluding numerous other pharmacogenomic tests. Only tests for guiding fluoropyrimidine and thiopurine medication dosing or managing severe toxicity from these medications will be covered.
Medium impact
Pharmacogenomics Testing - MEDICAID - FLORIDA (Revised)
Humana·Effective Apr 1, 2025
Humana Florida Medicaid has updated their pharmacogenomics testing policy, now covering only DPYD genotype testing (81232) and NUDT15/TPMT genotype testing (81306, 84433) for specific medication guidance indications. All other pharmacogenomics tests including comprehensive panels, behavioral health tests, and oncology-related tests are non-covered.

Related

All billing codes J3590 99213 99212 99202 99214 99203

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