Medicare AdvantageCoverageHigh impact
Minimal Residual Disease Testing - Medicare Advantage (Revised)
Humana·Oncology, Hematology, Pathology·Medicare Advantage
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Medicare Advantage revised its Minimal Residual Disease (MRD) testing policy effective 07/01/2026, establishing coverage criteria for MRD tests in both hematologic malignancies (e.g., ClonoSEQ) and solid tumors (e.g., Guardant360 Response, Signatera). The policy requires alignment with applicable CMS Local Coverage Determinations (LCDs) by Medicare Administrative Contractor jurisdiction and establishes medical necessity criteria based on analytical validity, clinical validity, and clinical utility. Billing teams must verify jurisdiction-specific LCD requirements and ensure proper prior authorization and documentation before claims submission.
Action Required
By June 30, 2026: (1) Billing team must map all service locations to their corresponding Medicare Administrative Contractor (MAC) jurisdiction and applicable LCD (e.g., MolDX L38835, L38822, L38814, L38779 depending on state). (2) Update billing software to require prior authorization verification against the applicable MAC's LCD requirements before processing MRD testing claims. (3) Providers must document medical necessity per CMS standards demonstrating analytical validity, clinical validity, and clinical utility for each MRD test ordered. (4) Identify covered MRD tests in your jurisdiction (examples: hematologic—ClonoSEQ, single gene PCR; solid tumors—Guardant Reveal, Guardant360 Response, NavDx, Oncodetect, Pathlight, RaDaR, Signatera) and create reference materials for ordering providers. (5) Front desk and clinical staff must verify patient is actively undergoing cancer treatment and that MRD testing is clinically indicated per treating physician judgment. Failure to obtain jurisdiction-specific prior authorization or meet medical necessity criteria will result in claim denials. Reference the Related CMS Documents table in the policy to identify your specific MAC and applicable LCD document numbers.