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    • Trek Health
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    v1.0.30
    OpenPayerPolicy UpdatesGenetic & Molecular TestingBlue Cross RI Melanoma GEP Coverage | OpenPayer
    Ask Trek AI about this page
    DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

    Gene Expression Profiling for Cutaneous Melanoma

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    This policy governs coverage of DecisionDx-Melanoma and myPath Melanoma gene expression tests for cutaneous melanoma or suspicious melanocytic lesions in Medicare Advantage Plans and Commercial Products, subject to applicable benefit documents.

    Policy Summary
    PayerBlue Cross Blue Shield - Rhode Island
    PolicyGene Expression Profiling for Cutaneous Melanoma
    Policy CodePolicy N/A
    Change TypeNo material clinical or coverage change
    Effective DateDec 1, 202623d
    Last ReviewAug 19, 2026
    Next Review DateN/A
    Key ActionReview the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine laboratory-test coverage and customized benefit provisions.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Gene expression tests addressed
    Not covered

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Medicare Advantage coverage
    Not medically necessaryCommercial product coverage
    31 genesDecisionDx-Melanoma gene content
    23 genesmyPath Melanoma gene content

    Coverage Criteria

    Medicare Advantage noncoverage

    For Medicare Advantage Plans

    Noncoverage: DecisionDx-Melanoma and myPath Melanoma are not covered for Medicare Advantage Plans.

    The policy identifies both tests as not covered.

    Commercial Products not medically necessary

    For Commercial Products

    Not medically necessary: DecisionDx-Melanoma and myPath Melanoma are not medically necessary for Commercial Products because the evidence is insufficient to determine the effects of the technology on health outcomes.

    The policy applies this determination to both addressed tests.

    Plan-specific coverage provisions

    Coverage is subject to the member's contract and benefit documents.

    Benefit verification: Review the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine laboratory-test coverage and applicable not covered or not medically necessary benefits and coverage.

    Benefits may vary between groups and contracts. Customized benefit coverage and contract exclusions, including exclusions for certain genetic testing services, may affect payment.

    DecisionDx-Melanoma and myPath Melanoma

    The following CPT code(s) are not covered for Medicare Advantage Plans and not medically necessary for Commercial Products.

    Noncovered melanoma gene expression profiling: Gene expression profiling for cutaneous melanoma billed with CPT codes 81529 or 0090U is not covered for Medicare Advantage Plans and is not medically necessary for Commercial Products.

    CPT 81529 applies to DecisionDx-Melanoma; CPT 0090U applies to myPath Melanoma.

    For Medicare Advantage Plans, DecisionDx-Melanoma and myPath Melanoma are not covered.

    DecisionDx-Melanoma billed with CPT 81529 is not covered for Medicare Advantage Plans and is not medically necessary for Commercial Products.

    myPath Melanoma billed with CPT 0090U is not covered for Medicare Advantage Plans and is not medically necessary for Commercial Products.

    For Commercial Products, DecisionDx-Melanoma and myPath Melanoma are not medically necessary because the evidence is insufficient to determine the effects of these technologies on health outcomes.

    DecisionDx-Melanoma and myPath Melanoma gene expression profiling are not medically necessary for Commercial Products.

    Coding and Test Identification

    Tests addressedCPT
    81529DecisionDx-Melanoma (Castle Biosciences)
    0090UmyPath Melanoma (Castle Biosciences)
    DecisionDx-MelanomaCPTNot Covered
    81529Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis
    myPath MelanomaCPTNot Covered
    0090UOncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 23 genes (14 content and 9 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as a categorical result (ie, benign, intermediate, malignant)

    Provider and Claims Guidance

    Documentation Required

    Review Member Benefit Documents

    Review the member’s applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement before determining coverage for laboratory or genetic testing services. These documents identify applicable covered, not covered, and not medically necessary benefits.

    • Confirm the member’s plan-specific laboratory testing coverage and exclusions.
    • Apply the benefit document governing the member’s group and contract.
    Denial Risk

    Policy Noncoverage

    For Medicare Advantage Plans, DecisionDx-Melanoma and myPath Melanoma are not covered. For Commercial Products, the evidence is insufficient to determine effects on health outcomes, and these tests are considered not medically necessary.

    • DecisionDx-Melanoma

    Clinical and Technical Background

    Gene expression profiling measures the activity of many genes simultaneously and may be used for diagnosis, disease classification, prognosis, surveillance, or prediction of treatment response. In cutaneous melanoma, the addressed tests analyze gene expression in pigmented lesions or melanoma tissue and have been proposed to aid biopsy decisions, interpretation of indeterminate histopathology, surveillance, adjuvant treatment decisions, or sentinel lymph node biopsy decisions.

    Definitions

    Gene expression profiling (GEP)
    DefinitionMeasurement of the activity of thousands of genes simultaneously to create a snapshot of cellular function.
    Clinical applicationsMay be used for disease diagnosis, disease classification, prediction of drug response, and prognosis.
    TechnologiesData are generated using molecular technologies including DNA microarrays, which measure activity relative to previously identified genes, and RNA-Seq, which directly sequences and quantifies RNA molecules.
    Clinically negative sentinel node basin
    DefinitionA clinically node-negative status with no signs of lymph node metastases.
    Physical examinationThe clinical assessment includes a negative physical examination.

    Not Covered Services

    DecisionDx-Melanoma is not covered for Medicare Advantage Plans and is not medically necessary for Commercial Products. myPath Melanoma is likewise not covered for Medicare Advantage Plans and is not medically necessary for Commercial Products.

    Policy Summary
    PayerBlue Cross Blue Shield - Rhode Island
    PolicyGene Expression Profiling for Cutaneous Melanoma
    Policy CodePolicy N/A
    Change TypeNo material clinical or coverage change
    Effective DateDec 1, 202623d
    Last ReviewAug 19, 2026
    Next Review DateN/A
    Key ActionReview the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine laboratory-test coverage and customized benefit provisions.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Test IdentificationProvider and Claims GuidanceClinical and Technical BackgroundDefinitionsNot Covered Services
  1. myPath Melanoma
    2. Billing Rule

    Plan-Specific Benefit Limitations

    Benefits may vary between groups and contracts. For Commercial Products, some genetic testing services may be excluded under the contract, including for self-funded groups that excluded expanded biomarker-testing coverage related to the state mandate, R.I.G.L. §27-19-81. Confirm whether the member’s plan has customized benefit coverage and consult the applicable Genetic Testing Services or Proprietary Laboratory Analyses policy coding section for services covered with prior authorization, not medically necessary, or excluded by contract.

    • Check group-specific and contract-specific benefit limitations.
    • Verify customized benefit coverage in the appropriate Benefit Booklet.
    • Review applicable exclusions and laboratory benefit limitations.
    • Consult the Coding section of the Genetic Testing Services or Proprietary Laboratory Analyses policies for coverage status and prior authorization requirements.
    • Refer to the Related Policies list for additional information.
    Denial Risk

    Melanoma Gene Expression Profiling Noncoverage

    Claims for the following melanoma gene expression profiling services are not covered for Medicare Advantage Plans and are not medically necessary for Commercial Products. Claims submitted for DecisionDx-Melanoma or myPath Melanoma may therefore be denied under the applicable plan and product rules.

    • CPT 81529 — Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), using formalin-fixed paraffin-embedded tissue; algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis. This code can be used for DecisionDx-Melanoma.
    • CPT 0090U — Oncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 23 genes (14 content and 9 housekeeping), using formalin-fixed paraffin-embedded (FFPE) tissue; algorithm reported as a categorical result (benign, intermediate, malignant). This code can be used for myPath Melanoma.
    Preoperative imagingThe clinical assessment includes a negative preoperative ultrasound.
    Add-on testing
    DefinitionTesting used in addition to another diagnostic method rather than as a replacement for it.
    myPath relationshipThe myPath test is meant to be used as an add-on to standard histopathology.
    Intended lesion typeThe test is intended for melanocytic lesions with indeterminate histopathologic features.