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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

June 2018

Prior Authorization No Longer Required for Cologuard Test


Effective for dates of service beginning June 11, 2018, Harvard Pilgrim will no longer require prior authorization for coverage of the colorectal cancer screening test Cologuard for commercial members.

We have removed the following CPT code from the Molecular Diagnostic Management prior authorization policy, as the test will now be covered without prior authorization:

  • 81528 – Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result
As a reminder, please continue to request prior authorization for other molecular diagnostic testing through AIM Specialty Health in one of the following ways:

For more information, refer to Harvard Pilgrim’s updated Molecular Diagnostic Management Medical Review Criteria.

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PUBLICATION INFORMATION

Robert Farias,
Senior Vice President, Corporate Network Strategy

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Writer

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