Next Generation Sequencing for Solid Tumors
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Policy governing medical necessity and prior authorization for specified next generation sequencing tissue tests for solid tumors for Medicare Advantage and Commercial products of Blue Cross Blue Shield - Rhode Island.
Specific proprietary NGS tissue tests and their CPT codes are listed as medically necessary effective 7/1/2026.
Prior authorization requirement for Medicare Advantage and recommended for Commercial products for the listed tests.
Coverage Criteria
Medically necessary tests with authorization
Covered when ALL of the following are met:
Applies to Medicare Advantage and Commercial Products (see prior authorization rules).
For self-funded groups that have contractually excluded the expanded coverage of biomarker testing under the state Biomarker Testing Mandate (R.I.G.L. §27-19-81), certain genetic testing services described in this policy may not be covered. Coverage for members in those groups depends on the group's benefit design and any contractual exclusions; refer to the group’s plan documents and related policy listings for specifics.
Benefits and coverage provisions for genetic testing can vary by group and contract. Always consult the member’s Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine whether a specific test or service is covered, subject to prior authorization, considered not medically necessary, or excluded due to contract language.
Covered Indications
Coding
Provider Actions & Authorization
Prior authorization required (Medicare Advantage); recommended (Commercial)
Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial Products via the online tool for participating providers for the listed tests (Oncotype MAP Pan-Cancer, Oncomap ExTra, Guardant360 TissueNext, Solid Tumor Expanded Panel, Strata Select).
- Applies to the five specified proprietary NGS tissue tests listed in the policy.
Provider impact — group benefit variations
Benefits and coverage may vary by group; some genetic testing services may be excluded for self-funded groups that have excluded expanded coverage of biomarker testing related to the state mandate.
Ordering physician must obtain authorization
Prior authorization must be obtained via the online authorization tool for participating providers, and only the ordering physician shall be involved in authorization, appeals, or other administrative processes related to prior authorization/medical necessity.
Unauthorized laboratory services will be denied
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.
Violation for laboratory‑supported authorization
If a laboratory or third party is found to have supported any portion of the authorization process on behalf of the ordering physician, BCBSRI will deem it a violation and may take severe action up to and including termination from the BCBSRI provider network.
Ordering physician responsible for authorization and appeals
Only the ordering physician shall be involved in authorization, appeal, or other administrative processes related to prior authorization and medical necessity; laboratories are not allowed to obtain clinical authorization or participate in the authorization process on the physician's behalf.
- Do not delegate authorization or appeals to laboratory representatives or third parties.
- Ensure documentation and any required submissions are prepared and submitted by the ordering physician.
Not Covered
Genetic testing services that are contractually excluded by a self-funded group’s benefit design related to the Biomarker Testing Mandate are not covered under this policy for those members. For groups with such exclusions, a detailed listing of which genetic testing services are covered with prior authorization, considered not medically necessary, or categorized as contract exclusions is available in the Coding section of the Genetic Testing Services or Proprietary Laboratory Analyses policies; verify coverage via the member’s plan documents.
Background
Next generation sequencing (NGS) is a sequencing methodology that captures genomic information across many genes simultaneously. NGS enables identification of genomic alterations with predictive, diagnostic, and prognostic utility to inform targeted therapies and precision medicine for common solid tumor types.
Definitions
Revision History
Added specific proprietary NGS tissue tests and their CPT codes as medically necessary when authorization criteria in the online tool are met (Oncotype MAP Pan-Cancer 0244U; Oncomap ExTra 0329U; Guardant360 TissueNext 0334U; Solid Tumor Expanded Panel 0379U; Strata Select 0391U).
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