Regarding Thyroid Nodule Molecular Testing Insurance Approval

posted: July 12, 2019

Molecular Testing for Indeterminate Thyroid Nodules

A prior approval is required of almost every insurance company in MA for the thyroid nodule molecular testing. As of January 2, 2019, none of the insurance companies in Massachusetts would allow ThyroSeq. With the effort of the NE AACE, both Afirma and ThyroSeq are generally accepted for indeterminate thyroid biopsies. The specific requirements are different for each insurance company are very fluid and may change from quarter to quarter.

As of 7/1/2019, here is the list of are the health plans that I work with and the correct responses for coverage:

• United Healthcare 3/13/2019: MD must do PA through Beacon Lab Benefits Solution. Indeterminate FNB (not defined which Bethesda class) and the results will be used to make decisions about surgery.
• BCBSMA and Carefirst 5/13/2019: MD is must do PA through AIM. Sign up for the AIM website for faster response. Bethesda III: Afirma. Bethesda III and IV: ThyroSeq 3.0 and ThyGenNEXT/ThraMIR and the results will be used to make decisions about surgery. Be sure you indicate there are no other clinical reasons for surgery (obstruction, invasion, metastatic nodes). None of the assays are allowed with cytology consistent with Hurthle cell pathology (just write down Bethesda III and IV and it will go through).
• BMC Healthnet 7/1/2019: CBL will do PA. Indeterminate thyroid nodule cytology (does not specify Bethesda) with either Afirma or Thyroseq v3 when the test will affect decision for surgery. Since the policy allows just one of these tests performed no more than once per member per episode of care you cannot biopsy 2 nodules on the same date).
• TAHP 4/25/2019: CBL will do PA but must do 2 FNB. Approval via InterQual: You MUST do 2 biopsies of all Bethesda III and IV cytology for coverage. Will not provide molecular testing if > 4 cm, if there are clinical indications for surgery (patient wants surgery, obstructive symptoms, invasion, metastatic nodes or if CT>17 pg/mL (if measured)) , and if planning other possible treatments (monitoring, thyroidectomy, partial thyroidectomy, other clinical information — do NOT select other treatments). Although their guideline does not say it accepts ThyroSeq (“comprehensive multi-gene panel for thyroid nodule”), they will approve this test and Afirma if all the criteria above are fulfilled.