Molecular testing for thyroid nodule evaluation
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Policy governing coverage and prior authorization for proprietary molecular and genomic tests used to risk-stratify thyroid fine-needle aspirate (FNA) results for Blue Cross Blue Shield - Rhode Island members, affecting Medicare Advantage and Commercial products and ordering providers.
ThyroSeq Cancer Risk Classifier (CRC), CPT Code 0287U, is considered medically necessary when medical criteria in the online authorization tool are met effective 2/1/2026.
Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products via the online tool for participating providers for ThyroSeq CRC (0287U) effective 2/1/2026.
Test coverage list updated to explicitly include Afirma GSC (81546), Afirma BRAF (81479), Afirma MTC (81479), RosettaGX Reveal (81479), ThyGeNEXT (0245U), ThyraMIR (0018U), and ThyroSeq (0026U) effective 2/1/2026.
Coverage Criteria
Covered molecular tests with prior authorization where applicable
Covered when ALL of the following payer-level conditions are met:
Ordering provider must obtain prior authorization as required by product type; specific clinical entry criteria are in the online authorization tool.
Some self-funded commercial groups may have contract exclusions that limit or exclude expanded biomarker testing coverage. Refer to the member's Benefit Booklet to determine whether the plan has customized exclusions for genetic or expanded biomarker tests and consult related policies for details.
Benefits and medical necessity determinations can vary by group and contract. Always consult the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for plan-specific limitations and to confirm whether a service is considered medically necessary under the member's coverage.
Coding
| 81546 | Afirma GSC |
| 0245U | ThyGeNEXT |
| 0018U | ThyraMIR |
| 0026U | ThyroSeq |
| 0287U | ThyroSeq Cancer Risk Classifier (CRC) |
| unlisted | Unlisted genetic testing CPT codes (used where no specific CPT exists) |
Provider Actions and Prior Authorization
Prior Authorization Required
Effective 2/1/2026, prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products via the online authorization tool for participating providers for ThyroSeq Cancer Risk Classifier (CRC) (CPT Code 0287U) and for all Unlisted genetic testing CPT codes so that BCBSRI can determine the specific service and medical necessity.
- ThyroSeq CRC (CBLPath, Inc / UPMC) — CPT 0287U
- All Unlisted genetic testing CPT codes — prior authorization required
Authorization Process Requirements
Laboratories are not permitted to obtain clinical authorization or otherwise participate in the authorization process on behalf of the ordering physician. Only the ordering physician may submit authorizations, appeals, or other administrative requests related to prior authorization and medical necessity.
- A laboratory, laboratory representative, or any third party with a relationship to a laboratory may not obtain authorization or facilitate any portion of the authorization or appeal process on behalf of the ordering physician.
- If BCBSRI determines a laboratory or third party supported any portion of the authorization process, this will be considered a violation and may result in termination from the BCBSRI provider network.
Unauthorized Services Denied
Services that have not been authorized through the BCBSRI online authorization process will be denied. If a laboratory provides a service without required authorization, the service will be denied and the financial liability will rest with the laboratory; the member may not be billed.
- Unauthorized services and laboratory services performed without the required online authorization will be denied.
- Denials related to unauthorized services may not be billed to the member; liability may be assigned to the performing laboratory.
Background
Thyroid nodules are common, and fine needle aspiration (FNA) cytology is the standard diagnostic procedure to distinguish benign from malignant lesions. While FNA reduces unnecessary surgery, approximately 20–30% of samples are cytologically indeterminate (for example, AUS/FLUS or follicular neoplasm categories) where cytologic features do not clearly distinguish benign from malignant disease and definitive diagnosis often requires surgical biopsy.
To improve risk stratification for indeterminate FNA results, molecular assays—including gene expression classifiers and tests that detect genetic variants—have been developed. These proprietary molecular tests can help estimate cancer risk and may reduce the number of diagnostic surgeries when used according to validated clinical criteria.
Definitions
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