Molecular Testing in the Management of Pulmonary Nodules
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - Rhode Island policy alerts
Know when Blue Cross Blue Shield - Rhode Island releases new policies or updates existing guidance.
Monitor payer policy activity
Policy governs use and coverage stance for plasma-based proteomic screening and bronchial brush gene expression profiling in the diagnostic workup of pulmonary nodules for Medicare Advantage and commercial products of Blue Cross Blue Shield - Rhode Island.
No material clinical or coverage changes in this revision.
Coverage Criteria
Coverage stance for REVEAL Lung Nodule Characterization
Policy note
This policy no longer addresses the test REVEAL Lung Nodule Characterization (MagArray). For details and any alternative guidance, see the Related Policies section.
Coverage and benefit determinations for molecular diagnostic testing vary by contract. Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine whether a requested service is covered or considered not medically necessary for that member.
Coding
| 0092U | Oncology (lung), three protein biomarkers, immunoassay using magnetic nanosensor technology, plasma, algorithm reported as risk score for likelihood of malignancy |
Provider Actions and Requirements
Prior authorization not applicable
Prior authorization is not required for Medicare Advantage Plans and Commercial Products for the test described in this policy.
No additional specified provider requirement
No specific provider action is specified in the policy text for step therapy or other requirements; follow member benefit verification and the provider call center guidance for member-specific questions.
Member benefit verification and consent
Verify member-specific benefits and eligibility with the provider call center before providing services, and document member agreement in writing if charging for services determined to be non‑covered.
- Call the provider call center for member-specific benefits and eligibility information.
- If services are determined to be non‑covered or not medically necessary and you plan to charge the member, obtain written member agreement in advance as required by the participation agreement.
Benefit variance may trigger denial
Benefits vary by contract; services that are not covered or are determined not medically necessary per the member’s Benefit Booklet, Evidence of Coverage, or Subscriber Agreement may be denied.
- Refer to the member’s Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to confirm coverage.
- Services determined not to be covered or not medically necessary can result in denial of payment.
Background
Plasma-based proteomic screening and bronchial brush gene expression profiling are molecular tests proposed to assist in risk stratification of pulmonary nodules. These tests aim to help identify patients who may avoid or require subsequent invasive diagnostic procedures such as CT-guided biopsy, bronchoscopy, or video-assisted thoracoscopic surgery. Such invasive procedures carry procedure-related complications ranging from post-procedure pain to pneumothorax.
Definitions
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.