Oncotype DX®

Is Testing Right for Me? I Have My Test Results

Oncotype DX®

Insurance Coverage

If you seek insurance coverage, you will have two options:

  1. Start the lab processing of your test immediately, and agree to cover any costs that your insurance will not cover.
  2. Request a Benefits Investigation to help determine if the Oncotype DX test is covered by your insurance, prior to testing. The company that performs the Oncotype DX test, Genomic Health, has a program called GAP (Genomic Access Program). The GAP program helps determine and secure insurance coverage for Oncotype DX testing. Genomic Health also offers a financial assistance program based on financial eligibility. In cases where a claim is denied on first review, the GAP program can help in appealing the denial, along with input from your doctor.

To secure reimbursement for the cost of testing, most insurance companies will ask you for the following:

  • CPT Codes. These codes tell the company what lab work was done, and how much their policy will pay for it.
  • ICD-9 Codes. These codes specify a medical diagnosis. Your doctor will need to provide these codes. If a letter of medical necessity is required, ICD-9 codes can be included in the letter.
  • Letter of Medical Necessity. Some insurance companies need a letter from your doctor that confirms this testing is medically important.
  • Preauthorization. Some insurers require a prior authorization before processing a specimen for Oncotype DX testing. This usually will involve your doctor, but the GAP program can also help facilitate this process.

Insurance policies usually cover testing according to medical necessity. Some insurance companies will reimburse you if you are testing with Oncotype DX because:

  • You were recently diagnosed with early-stage breast cancer AND
  • Your lymph nodes are cancer free AND
  • Your cancer is hormone receptor-positive AND
  • You are healthy enough to receive chemotherapy

Insurance companies may be less likely to reimburse if:

  • You already started treatment
  • You are a poor chemotherapy candidate due to age or illness
  • They are unfamiliar with Oncotype DX and consider it experimental
Next: Pros and Cons