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Molecular and Genomic Testing Program Update: Cologuard®

Effective August 23, 2018, CPT® code 81528 (Cologuard®) has been removed from our Molecular and Genomic Testing Program, administered by eviCore healthcare (eviCore) for members enrolled in Horizon BCBSNJ fully-insured products as well as administrative services only (ASO) accounts that have elected to participate in the Molecular and Genomic Testing Program.

Beginning with services provided on and after August 23, 2018, eviCore will no longer conduct pre-service Medical Necessity Determination (MND) reviews of CPT code 81528 when rendered in a physician’s office or clinical laboratory¹.

Review the updated list of molecular and genomic diagnostic testing services that require pre-service MND reviews.

More information about this program is on our Molecular and Genomic Testing Program web page.

If you have questions, contact your Network Specialist or Ancillary Contracting Specialist.

¹ MND requirements will also not apply to molecular and genomic diagnostic testing services rendered to patients in a hospital Emergency Room (ER), hospital outpatient or inpatient setting, or an Ambulatory Surgery Center (ASC).

Pre-service MND reviews

To obtain pre-service MND from eviCore (or to validate that a pre-service MND was requested and/or approved):

  • Visit eviCore.com, or
  • Call 1-844-224-0493, between 7 a.m. and 7 p.m., Eastern Time.

The guidelines eviCore uses to conduct MND reviews for the Molecular and Genomic Testing Program may be accessed www.evicore.com/healthplan/Horizon_Lab.

Cologuard® is a registered trademark of Exact Sciences Corporation.

CPT® is a registered trademark of the American Medical Association.

Published on: August 16, 2018, 14:18 p.m. ET
Last updated on: September 14, 2018, 06:38 a.m. ET