CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Decipher Bladder TURBT Policy

Policy governing coverage and prior authorization requirements for the Decipher Bladder TURBT proprietary molecular test (Decipher Biosciences) for Medicare Advantage and commercial members when medical criteria in the online authorization tool are met.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDecipher Bladder TURBT Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2025

Next Review Date

Key ActionObtain prior authorization via the online authorization tool (required for Medicare Advantage; recommended for Commercial) initiated by the ordering physician.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes

1CPT code covered

2Plan types referenced

Coverage Summary

Policy governing coverage and prior authorization requirements for the proprietary molecular test Decipher Bladder TURBT (Decipher Biosciences).

Coverage stance: covered with criteria. Effective date: 08/01/2025. Applies to Medicare Advantage and Commercial plans.

Key policy facts

Effective date08/01/2025

Last review06/18/2025

StatusCURRENT

SubjectDecipher Bladder TURBT molecular test

Scope summaryPolicy governing coverage and prior authorization requirements for the Decipher Bladder TURBT proprietary molecular test (Decipher Biosciences) for Medicare Advantage and Commercial members when medical criteria in the online authorization tool are met.

Medical-Necessity Criteria

Medically necessary criteria

Effective 08/01/2025, the following test(s) are considered medically necessary when the medical criteria in the online authorization tool for participating providers is met:

ALL of the following

Test is Decipher Bladder TURBT (Decipher Biosciences, CPT 0016M)
Medical criteria in the online authorization tool for participating providers are met
Applies to Medicare Advantage Plans and Commercial Products

Provider Actions

Prior Authorization

Prior authorization required (Medicare Advantage) / Recommended (Commercial)

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products via the online authorization tool for participating providers. The ordering physician must initiate and participate in the authorization and appeal processes; laboratories and third parties may not obtain authorization on behalf of the ordering physician.

0016M

Denial Risk

Unauthorized laboratory services may be denied and billed to lab

If a laboratory provides a laboratory service that has not been authorized, the service will be denied as the financial liability of the participating laboratory and may not be billed to the member.

0016M

Documentation Required

Ordering physician responsibility for authorization documentation

Only the ordering physician shall be involved in the authorization, appeal, or other administrative processes related to authorization/medical necessity. Involvement of a laboratory or third party in obtaining authorization is a violation and may result in termination from the BCBSRI provider network.

Background

Molecular subtyping can aid in identifying bladder cancer type, assessing the risk and benefit of treatments, and help diagnose bladder cancer profile subtypes. The Decipher Bladder TURBT test is a proprietary molecular subtyping assay intended to analyze transurethral resection of bladder tumor (TURBT) specimens to inform clinical decision-making in bladder cancer.

This policy addresses coverage of the Decipher Bladder TURBT test (Decipher Biosciences, CPT 0016M) and establishes that the test may be considered medically necessary when the medical criteria in the online authorization tool for participating providers are met. Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products.

Definition: Decipher Bladder TURBT — Proprietary molecular subtyping test from Decipher Biosciences intended for transurethral resection of bladder tumor (TURBT) specimens.