Molecular Markers in Fine Needle Aspiration of the Thyroid
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This policy governs coverage and prior authorization for specified molecular assays performed on thyroid fine needle aspiration (FNA) specimens for Blue Cross Blue Shield - Rhode Island members (Medicare Advantage and Commercial plans). It defines which tests are covered, which may be medically necessary with criteria, and prior authorization requirements for participating providers.
ThyroSeq Cancer Risk Classifier (CRC) (CPT Code 0287U) is listed as medically necessary when medical criteria in the online authorization tool are met.
Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products via the online tool for ThyroSeq CRC (0287U).
A list of specific molecular assays (Afirma GSC, Afirma BRAF, Afirma MTC, RosettaGX Reveal, ThyGeNEXT, ThyraMIR, ThyroSeq) are explicitly covered effective 2/1/2026.
Coverage and Medical Necessity
Coverage stance
Covered when listed below or when medical criteria in the online authorization tool are met.
These tests are listed as covered for Medicare Advantage Plans and Commercial Products effective 2/1/2026.
Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products; authorization determinations follow the online tool for participating providers.
Some genetic testing services may be a contract exclusion for certain self‑funded groups that have excluded expanded biomarker testing coverage per the state mandate (R.I.G.L. §27‑1981). Members and providers should consult the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine whether a particular genetic test is excluded under the member's customized plan benefits. For groups with exclusions, the Coding sections of the Genetic Testing Services and Proprietary Laboratory Analyses (PLA) policies list which services require prior authorization, are not medically necessary, or are contract exclusions.
This policy does not provide a separate, explicit list of tests that are declared "not medically necessary." Coverage determinations depend on the member's contract benefits and on medical necessity determinations made through the online prior authorization tool for participating providers. In particular, ThyroSeq CRC (CPT 0287U) is addressed through the online authorization process and requires prior authorization for Medicare Advantage Plans (recommended for Commercial Products); unlisted genetic testing CPT codes also require prior authorization to establish what service is being rendered and whether it meets medical necessity criteria. Providers should use the online tool and consult the member's Benefit Booklet to confirm coverage.
Coding and Test List
| 81546 | Afirma GSC (Genomic Sequencing Classifier) |
| 0245U | ThyGeNEXT |
| 0018U | ThyraMIR |
| 0026U | ThyroSeq |
| 0287U | ThyroSeq Cancer Risk Classifier (CRC) |
Authorization, Billing, and Provider Responsibilities
Prior authorization required for ThyroSeq CRC (0287U)
Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products via the online tool for participating providers for ThyroSeq CRC (CPT 0287U).
- Authorization must be obtained via the online tool by the ordering physician (laboratories may not obtain authorization on behalf of the ordering physician).
No step therapy requirements specified
No step therapy requirements are specified in this policy for molecular marker testing of thyroid FNA specimens.
Authorization required for Unlisted genetic testing CPT codes
All Unlisted genetic testing CPT codes require prior authorization to determine the service rendered and medical necessity; authorization must be obtained via the online tool by the ordering physician.
- There is no specific CPT coding for some services referenced; use an Unlisted CPT code and obtain prior authorization to confirm coverage or medical necessity.
- Laboratories are not allowed to obtain authorization or participate on behalf of the ordering physician.
Unauthorized laboratory services will be denied
If a laboratory provides a laboratory service that has not been authorized, the service will be denied and the financial liability will rest with the participating laboratory; the service may not be billed to the member.
- BCBSRI may take severe action, up to termination from the provider network, if a laboratory or third party is found to have improperly obtained authorization.
Clinical Background
Thyroid nodules are common and the majority are benign. Fine needle aspiration (FNA) cytology is the principal diagnostic tool for evaluating nodules, but approximately 20–30% of FNA results are cytologically indeterminate (for example, atypia of undetermined significance/follicular lesion of undetermined significance [AUS/FLUS] or follicular neoplasm). Indeterminate cytology frequently leads to diagnostic surgical resection; molecular marker assays and gene expression classifiers are used to improve risk stratification of indeterminate nodules and may reduce unnecessary surgeries.
Key Terms and Test Definitions
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