Pharmacogenomics Testing | UHC Coverage Update

TL;DR: UnitedHealthcare modified its pharmacogenomics testing coverage policy for Medicare Advantage, effective March 2, 2026. Here's what billing teams need to do before claims start hitting the wall.

UnitedHealthcare updated its pharmacogenomics testing Medicare Advantage medical policy (policy code: pharmacogenomics-testing) to clarify covered and non-covered indications for single gene tests, multi-gene panels, and combinatorial pharmacogenomic tests. The change directly affects how you bill CPT codes 81335, 81230, 81346, 0031U, 0032U, 0033U, 0117U, 0173U, and 0175U. If your practice orders pharmacogenomic testing for oncology, rheumatology, or psychiatry patients on Medicare Advantage, this policy change affects your reimbursement.

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Quick-Reference Table

Field	Detail Copy
Payer	UnitedHealthcare
Policy	Pharmacogenomics Testing – Medicare Advantage Medical Policy
Policy Code	pharmacogenomics-testing
Change Type	Modified
Effective Date	March 2, 2026
Impact Level	High
Specialties Affected	Oncology, Hematology, Rheumatology, Transplant Medicine, Psychiatry, Pain Management
Key Action	Audit open and pending claims for non-covered codes (0031U, 0032U, 0173U, 0175U, 0117U) and update order workflows to match CPIC level A/B or FDA table criteria before March 2, 2026

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UnitedHealthcare Pharmacogenomics Testing Coverage Criteria and Medical Necessity Requirements 2026

The UHC pharmacogenomics testing coverage policy sets two hard requirements for medical necessity. Both must be met before a test qualifies for coverage.

Requirement one: The patient has a diagnosed condition. And clinical evaluation has determined that the patient needs a medication with a known gene-drug interaction. The test result must directly change how you manage that drug for that condition. "Ordered to rule things out" doesn't cut it here.

Requirement two: The test must meet one of two evidence thresholds. Either it's evaluated by Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines at level A or B, or it appears in the FDA Table of Pharmacogenomic Biomarkers in Drug Labeling or the FDA Table of Pharmacogenetic Associations where data support therapeutic recommendations, safety impact, or drug response.

CPIC level C tests — where the consortium explicitly says "no recommendation" — are not covered. That's not a gray area. UHC is using CPIC's own tiering system as the cutoff line.

This matters because a lot of labs market panel tests using CPIC as a credential without telling your ordering physicians which genes in the panel are level A, which are level B, and which are level C. Your billing team is left holding the denial. Pull the CPIC level for every gene on every panel before you bill.

Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) from the relevant Medicare Administrative Contractor govern where they exist. UHC requires compliance with those LCD/LCA policies first. The UHC coverage criteria below apply only where no LCD/LCA exists or where the LCD/LCA is silent on a specific indication. Know your MAC's jurisdiction before you submit.

For warfarin pharmacogenomics specifically, CMS National Coverage Determination 90.1 applies. This UHC policy does not supersede NCD 90.1 for warfarin response testing.

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UnitedHealthcare Pharmacogenomics Testing Exclusions and Non-Covered Indications

Several specific genes, panels, and test types are explicitly non-covered under this policy. These aren't judgment calls — they're named exclusions.

CYP1A2 (CPT 0031U): Testing for rucaparib dosing is not covered. UHC's rationale: CYP1A2 genotype polymorphisms don't have a clinically meaningful effect on rucaparib pharmacokinetics.

CYP3A4 (CPT 81230): Statin dosing tests are not covered. CPIC has assigned level C — no recommendation — due to insufficient evidence for clinical implementation. No CPIC recommendation, no coverage.

COMT (CPT 0032U): Opioid dosing tests based on COMT genotype are not covered. Again, CPIC level C. There are no therapeutic recommendations for dosing opioids based on COMT genotype.

HTR2A/HTR2C panel (CPT 0033U): This code was deleted December 31, 2025. Do not bill it. If it's still in your charge master or your lab's order menu, remove it now.

Psych HealthPGx Panel and Genomind Professional PGx Express CORE (CPT 0173U and 0175U): Both panels are explicitly called out as not reasonable and necessary for pharmacogenomic testing. These are named panel products. If your psychiatry department orders either of these for Medicare Advantage patients, expect denials.

Urinary biomarker tests for chronic pain (CPT 0117U): Not covered. The policy categorizes these under "Foundation PI" and states they are not reasonable and necessary.

The real issue here is that several of these non-covered tests are aggressively marketed to physicians — especially 0173U and 0175U for psychiatric medication management. Your clinical team may not know these are excluded. That's a claim denial waiting to happen, and it's an education problem as much as a billing problem.

If your practice has ongoing orders for any of these codes for UHC Medicare Advantage patients, loop in your compliance officer before the effective date of March 2, 2026.

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Coverage Indications at a Glance

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UnitedHealthcare Pharmacogenomics Testing Billing Guidelines and Action Items 2026

These are the steps your billing and revenue cycle team should take now. The effective date is March 2, 2026.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Pharmacogenomics Testing Under Policy Code pharmacogenomics-testing

Covered CPT Codes (When Medical Necessity Criteria Are Met)

Code	Type	Description Copy
81335	CPT	TPMT (thiopurine S-methyltransferase) gene analysis, common variants — drug metabolism; CPIC level A
81346	CPT	TYMS (thymidylate synthetase) gene analysis, common variants — 5-fluorouracil/5-FU drug metabolism

Non-Covered CPT Codes

Key ICD-10-CM Diagnosis Codes

These diagnosis codes appear in the policy and represent conditions where covered pharmacogenomics testing — particularly TPMT testing for thiopurine dosing — may apply.

Note the deletions on several C91 codes effective 07/12/2025. If your team has been using C91.11, C91.12, or C91.30, update your diagnosis code mapping now. Submitting deleted ICD-10 codes is a clean path to a claim denial.

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