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

August 2018

Prior Authorization No Longer Required for Cologuard Test


In the June issue of Network Matters, Harvard Pilgrim communicated that we will no longer require prior authorization for coverage of the colorectal cancer screening test Cologuard for commercial members. This same change also applies to members of Harvard Pilgrim’s StrideSM (HMO) Medicare Advantage plans.

We have removed the following CPT code from the Stride Molecular Diagnostic Management prior authorization policy, as the test is now 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 for commercial and Stride members through AIM Specialty Health in one of the following ways:

For more information, refer to Harvard Pilgrim’s updated StrideSM (HMO) Medicare Advantage Molecular Diagnostic Management Medical Review Criteria.

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PUBLICATION INFORMATION

Robert Farias,
Senior Vice President, Corporate Network Strategy

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator