Medical Policy Updates

Notification of Policy Revisions Effective December 10, 2019 (Posted October 15, 2019)

Medical Policy Revision
Gene Expression Testing for Breast Cancer Prognosis AHS-M2020 "Notification" Wording in When Covered section changed from "Reimbursement is allowed..." to "is considered Medically Necessary." Item 2 revised to read: Use of EndoPredict or PAM50 (Prosigna), to determine recurrence risk for deciding whether to undergo adjuvant chemotherapy in women with primary, invasive breast cancer with the same characteristics as considered for Oncotype DX (1A- 1I); with one exception-for individuals with 1-3 involved ipsilateral axillary lymph nodes the tests are considered investigational). Wording in the When Not Covered section changed from "Reimbursement is not allowed..." to "is considered Investigational." Item 2 moved from this section to the revised statement in Item 2 above. Following statement is corrected to read: Use of gene expression assays in men are considered investigational. Policy remains on notice for effective date 12/10/2019.