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Genetic Testing for Hereditary Cancer - Medicare Advantage (Revised)

Humana·IA, KS, MO, NE, IN, MI, IL, MN, WI, CT, NY, ME, MA, NH, RI, VT, KY, OH, CA, HI, NV, AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY, AR, CO, NM, OK, TX, LA, MS, DE, DC, MD, NJ, PA, AL, GA, TN, NC, SC, VA, WV, FL, PR · Oncology, Genetics, Pathology·Medicare Advantage
Effective date
Aug 3, 2026
We identified it
Aug 4, 2026
Days to comply
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Summary

This is a comprehensive Medicare Advantage policy on genetic testing for hereditary cancer syndromes, effective August 3, 2026. The policy establishes coverage guidelines for germline genetic testing across multiple cancer types (melanoma, gastric cancer, neuroendocrine tumors, renal cell carcinoma, and others) and references specific MAC-based Local Coverage Determinations (LCDs) that vary by geographic jurisdiction. Billing teams must verify applicable MAC jurisdiction and LCD requirements before processing claims.

Action Required

Action needed
By August 3, 2026: Billing team must (1) map practice locations to applicable Medicare Administrative Contractor (MAC) jurisdictions using the policy's geographic reference table (J5, J8, J6, JK, J15, KY/OH, JE, JF, JH, JL, JJ, JM, JN); (2) obtain and implement the corresponding MolDX and/or molecular pathology LCDs for each jurisdiction (e.g., L39040, L36807, L38429 for J5/J8 MAC); (3) update billing system rules to require prior authorization verification against the applicable LCD before submitting genetic testing claims; (4) train coding staff on the specific coverage limitations and medical necessity documentation requirements outlined in each MAC's LCD; (5) establish internal process to route genetic testing claims to the correct MAC based on service location. Failure to apply correct MAC-specific LCD requirements will result in claim denials and payment delays. Reference the related policies listed (Comprehensive Genomic Profiling, Hereditary Breast/Ovarian/Pancreatic/Prostate Cancer, Hereditary Colorectal/Uterine Cancer, and Single Gene/Molecular Biomarker Testing) for additional coverage context.

Related policy hubs

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