CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer

Policy governing medical necessity and coverage for GEP and ctDNA prognostic tests to predict recurrence risk in patients with stage II or III colon cancer following surgery for members of BCBSRI Medicare Advantage and commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyGene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical changes

Effective Date01|01|2024

Next Review DateN/A

Key ActionOrdering physician must handle authorization and may not delegate authorization or appeals to a laboratory or its representative.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

81525CPT code for Oncotype DX Colon Recurrence Score

stage II or IIIClinical population for testing

01|01|2024Effective date

10|02|2024Policy last reviewed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Medically Necessary Indication — Oncotype DX Colon Recurrence Score (CPT 81525)

Covered when ALL of the following are met for Medicare Advantage and Commercial Products:

Medically Necessary Indication: Test: Oncotype DX Colon Recurrence Score (CPT 81525)ICD-10: C18.0-C20, C21.1

Applies following surgical resection for stage II or III colon cancer. Laboratories may not obtain authorization on behalf of the ordering physician; only the ordering physician shall be involved in authorization, appeals, or other administrative processes.

For self‑funded groups, coverage for genetic testing services may be limited when the employer’s contract excludes the expanded biomarker testing coverage established by the state mandate (R.I.G.L. §27‑19‑81). Members whose plans are subject to such contract exclusions should consult their Benefit Booklet to determine whether the testing is covered, and reference the Genetic Testing Services and Proprietary Laboratory Analyses policies for lists of tests that require prior authorization, are not medically necessary, or are excluded.

No additional medical necessity criteria are specified in this document; the policy indicates Medical Criteria: Not applicable for the tests addressed.

Covered Indications

Prognostic testing for recurrence risk in stage II or III colon cancer following surgery using the Oncotype DX Colon Recurrence Score (CPT 81525).

Prognostic testing for recurrence risk in stage II or III colon cancer following surgical resection:

Covered Indication: Prognostic testing for recurrence risk using the Oncotype DX Colon Recurrence Score (CPT 81525)Clinical population: stage II or III colon cancer following surgery

Test described as Oncotype DX Colon Recurrence Score (Exact Sciences); CPT code 81525.

Provider Actions & Authorization

Prior Authorization

Prior Authorization Restrictions

Prior authorization is not applicable for this policy. Laboratories are not allowed to obtain clinical authorization or participate in the authorization process on behalf of the ordering physician. Only the ordering physician shall be involved in the authorization, appeal, or other administrative processes related to prior authorization/medical necessity.

Prior authorization: Not applicable to this policy.
Only the ordering physician may request, manage, appeal, or otherwise participate in prior authorization/medical necessity processes.
Laboratories or their representatives may not obtain authorization or assist in authorization or appeals on behalf of the ordering physician.

Denial Risk

Unauthorized Authorization — Denial & Liability

If a laboratory, laboratory representative, or any third party is found to have supported or performed any portion of the authorization process on behalf of the ordering physician, BCBSRI will treat that action as a violation of policy and may take severe action up to and including termination from the BCBSRI provider network. Services provided by a laboratory that have not been properly authorized will be denied and considered the financial liability of the providing laboratory or ordering provider/group, and may not be billed to the member.

Unauthorized authorizations obtained by labs or third parties will result in denial of the service.
Financial responsibility for unauthorized services rests with the providing laboratory or ordering provider/group, not the member.
Violations may result in termination from the BCBSRI provider network.

Note

Ordering Physician Responsibility

Ordering providers must personally handle authorization, appeals, and all administrative communications related to prior authorization and medical necessity for the tests covered under this policy. Laboratories may not prepare or submit supporting documentation for authorization on behalf of the ordering physician.

Only the ordering physician shall be involved in authorization, appeal, or other administrative processes.
Labs may not prepare or submit clinical rationale or supporting documentation for authorization on behalf of the ordering physician.

Documentation Required

Provider Actions

Provider action: Ensure that all prior authorization and appeal activities are initiated and managed by the ordering physician or the physician's authorized internal staff. Do not rely on laboratories or external representatives to obtain authorizations. Verify authorization status before performing services.

Verify authorization status prior to ordering or performing the test.
Do not permit laboratories or third parties to obtain or manage authorizations on the provider's behalf.
If authorization was not obtained by the ordering physician, expect denials and financial liability.

Background

Gene expression profile (GEP) assays and circulating tumor DNA (ctDNA) tests are used as prognostic tools to estimate recurrence risk after surgical resection for colon cancer. These tests are intended to identify patients—classically those with stage II disease (and in some evidence, selected stage III patients)—who are at higher risk of recurrence and therefore may derive benefit from adjuvant chemotherapy. Standard clinical factors that inform adjuvant therapy decisions include tumor substage (for example, T4), obstruction or perforation, inadequate lymph node sampling (<12 nodes), aggressive histology, margin status, and microsatellite instability/mismatch repair (MSI/MMR) status.

OpenPayer

Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer

Coverage Criteria

Covered Indications

Coding

Provider Actions & Authorization

Not Covered

Background

Definitions

C18.0-C20	Malignant neoplasm of colon and rectum range
C21.1	Malignant neoplasm of anal canal