New Mexico § 13-7-40 - Biomarker testing insurer coverage

§ 13-7-40. Biomarker testing insurer coverage

A. Group health coverage, including self-insurance, offered, issued, amended, delivered

or renewed under the Health Care Purchasing Act shall provide coverage for insureds

to receive biomarker testing. B. Coverage provided pursuant to this section shall be for the purposes of diagnosis,

treatment, appropriate management or ongoing monitoring of an insured's disease or

condition when the test is supported by medical and scientific evidence, including: (1) labeled indications for a United States food and drug administration-approved

or -cleared test; (2) indicated tests for a United States food and drug administration-approved drug; (3) warnings and precautions on United States food and drug administration labels; (4) federal centers for medicare and medicaid services national coverage determinations

or medicare administrative contractor local coverage determinations; or (5) nationally recognized clinical practice guidelines. C. An insurer providing coverage for biomarker testing pursuant to this section shall

ensure that: (1) coverage is provided in a manner that limits disruptions in care, including coverage

for multiple biopsies or biospecimen samples; and (2) a patient and a practitioner who prescribes biomarker testing have clear, accessible

and convenient processes to request an appeal of a benefit denial by the insurer and

that those processes are accessible on the insurer's website. D. Coverage for biomarker testing may be subject to deductibles and coinsurance consistent

with those imposed on other benefits under the same group health care coverage, including

any form of self-insurance. E. The provisions of this section do not apply to accident-only or limited or specified

disease policies, plans or certificates of health insurance. F. As used in this section: (1) “ biomarker ” means a characteristic that is objectively measured and evaluated as an indicator

of normal biological processes, pathogenic processes or pharmacologic responses to

a specific therapeutic intervention, including known gene-drug interactions for medications

being considered for use or already being administered. “Biomarker” includes gene mutations, characteristics of genes or protein expression; (2) “ biomarker testing ” means analysis of a patient's tissue, blood or other biospecimen for the presence

of a biomarker and includes single-analyte tests, multi-plex panel tests, protein

expression and whole exome, whole genome and whole transcriptome sequencing; and (3) “ nationally recognized clinical practice guidelines ” means evidence-based clinical practice guidelines that are: (a) developed by independent organizations or medical professional societies using

a transparent methodology and reporting structure and with a conflict-of-interest

policy; and (b) used to establish standards of care informed by a systematic review of evidence

and an assessment of the benefits and risks of alternative care options and include

recommendations intended to optimize patient care.