Coverage for Genetic Testing for Breast Cancer

Tuesday, September 15, 2020

Effective Sept. 1, 2020, the North Carolina Medicaid and NC Health Choice Programs will cover the following genomic tests used for breast cancer treatment as part of Clinical Coverage policy 1S-7, Gene Expression Profiling for Breast Cancer:

  • Oncotype Dx
  • EndoPredict

The following codes will be used to report gene expression profiling:

  • 81519 - Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score Oncotype DX®, Genomic Health.
  • 81522 - Oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes (eight content and four housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk score EndoPredict®, Myriad Genetic Laboratories, Inc.

Please refer to NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, clinical coverage policies and any other relevant documents for specific coverage and reimbursement for Medicaid and NC Health Choice.

Contact

GDIT, 1-800-688-6696