Skip to main content

Medical Policy Revision: Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

Effective October 30, 2017, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for the use of the 21-gene reverse transcriptase-polymerase chain reaction (RT-PCR) assay (i.e., Oncotype DX®) to determine recurrence risk for deciding whether or not to undergo adjuvant chemotherapy in women with primary, invasive breast cancer.

Our revised medical policy, Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer, identifies when the use of the 21-gene reverse transcriptase-polymerase chain reaction (RT-PCR) assay (i.e., Oncotype DX) to determine breast cancer recurrence risk would be considered medically necessary or investigational.

We encourage you to review this policy in our Medical Policy Manual.


Based on the guidelines of our revised medical policy, Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer:

  • Claims submitted for services provided on and after October 30, 2017 that include CPT code 81519, depending on the submitted diagnosis code(s), may pend while information is requested from the referring physician and reviewed to determine if the service in question is to be considered medically necessary or a non-covered investigational service.
  • HCPCS code S3854 included on claims for services provided on and after October 30, 2017, regardless of the submitted diagnosis code(s), will be denied as a non-covered investigational service.
  • Claims submitted for services provided on and after October 30, 2017 to members enrolled in Horizon BCBSNJ Medicare Advantage plans that include CPT code 0008M, regardless of the submitted diagnosis code(s), will pend while information is requested and reviewed to determine if the service in question is to be considered medically necessary or a non-covered investigational service.
  • CPT code 0008M included on claims for services provided on and after October 30, 2017 to members enrolled in all Horizon BCBSNJ plans other than Medicare Advantage plans, regardless of the submitted diagnosis code(s), will be denied as a non-covered investigational service.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after October 30, 2017.

Published on: August 1, 2017, 11:57 a.m. ET
Last updated on: August 1, 2017, 11:59 a.m. ET