MedicaidCoverageMedium impact
BT202010: IHCP expands coverage for genetic testing for breast cancer recurrence
Indiana Medicaid (IHCP)·IN · Oncology, General Surgery·Medical Policy
Effective date
Mar 11, 2020
We identified it
Jun 19, 2026
Summary
Indiana Health Coverage Programs (IHCP) added coverage for EndoPredict gene assay for breast cancer recurrence using CPT code 81522, effective March 11, 2020. Prior authorization is required with specific clinical criteria including ER+/HER2- breast cancer patients with completed surgery and pathological evaluation.
Action Required
Billing team must update system to require prior authorization for CPT 81522 (EndoPredict gene assay) for IHCP/Medicaid patients. Verify all clinical criteria are met before ordering: patient must have ER+/HER2- breast cancer, completed surgery with pathological evaluation, specific histology types, tumor size 0.6-4.0 cm with other specified parameters, and chemotherapy must be under consideration. Test is limited to once per lifetime per member.