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Member and Recipient Service Line: 1-877-685-2415
Provider Support Service Line: 1-855-250-1539
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
The provider(s) shall submit the following: a. the prior approval request; and b. all health records and any other records that support the beneficiary has met the specific criteria in Subsection 3.2 of this policy.
Conditional Requirements
Prior authorization may be required. Check North Carolina clinical coverage policy 1S-10, Genetic Testing for Carrier and Prenatal for more information
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
Genetic Testing for Carrier and Clinical Coverage Policy No:1S-10 Prenatal
Carrier genetic screening is a type of genetic test carried out to detect a beneficiary who may be susceptible to producing offspring with inherited recessive single gene disorders. While carriers themselves are typically unaffected by the disease, they can transmit harmful genetic variations to their children. This screening can be conducted during the preconception or prenatal stages. Prenatal genetic tests consist of non-invasive prenatal testing (cell-free DNA testing, nuchal translucency ultrasound), and prenatal diagnostic testing (amniocentesis, CVS), which are aspects of prenatal care that focus on detecting problems with the pregnancy as early as possible. These may be anatomic and physiologic problems with the health of the zygote, embryo, or fetus, either before gestation even starts or as early in gestation as practicable. A screening test can detect problems such as neural tube defects, chromosome abnormalities, and gene mutations that would lead to genetic disorders and birth defects, such as spina bifida, cleft palate, Down syndrome, Tay–Sachs disease, sickle cell anemia, thalassemia, cystic fibrosis, muscular dystrophy, and fragile X syndrome. Some tests are designed to discover problems which primarily affect the health of the mother, such as Pregnancy-Associated Plasma Protein A (PAPPA) to predict pre-eclampsia or glucose tolerance tests to diagnose gestational diabetes. Screening tests can also detect anatomical defects such as hydrocephalus, anencephaly, heart defects, and amniotic band syndrome.
Authorization Guidelines
The provider(s) shall submit the following: a. the prior approval request; and b. all health records and any other records that support the beneficiary has met the specific criteria in Subsection 3.2 of this policy.
Conditional Requirements
Prior authorization may be required. Check North Carolina clinical coverage policy 1S-10, Genetic Testing for Carrier and Prenatal for more information
Limits
Medicaid shall not cover whole exome sequencing (WES) or whole genome sequencing (WGS) for ANY of the following scenarios:
- 1. When the CCP criteria are not met;
- 2. For uncomplicated autism spectrum disorder, developmental delay, and
mild to moderate global developmental delay;
- 3. For screening during pregnancy to diagnose fetal conditions;
- 4. For testing an embryo before implantation;
- 5. For screening genetic carriers;
- 6. Genetic disorders in every other circumstance; or
- 7. The test is used to determine ancestry.
Comparator genome sequence analysis requires that whole genome sequencing be performed simultaneously or have been previously performed. For whole genome sequencing beneficiary must be currently admitted to or recently discharged from a NICU or PICU
Length of Stay
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements)
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
The provider(s) shall submit the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in this policy.
When the provider requests additional units then, in addition to the prior approval requirements noted above, the provider shall submit all of the following supporting documentation to justify the request:
- a. The reason for the test(s);
- b. Previous related lab results;
- c. How the test results contribute to improved health outcomes; and
- d. How the test results alter the beneficiary’s treatment and management.
Conditional Requirements
Prior authorization may be required. Check North Carolina clinical coverage policy 1S-10, Genetic Testing for Carrier and Prenatal for more information
Limits
once in a lifetime
Exclusions
Gene panels are not covered when when the same test is repeated after a negative result, when the test is repeated despite a once-in-a-lifetime limitation, when the test is for beneficiary family members, when the procedure duplicates another provider's procedure, product, or service, or when the procedure is experimental, investigational, or part of a clinical trial. For BRCA-related cancers, Medicaid does not cover repeat BRCA1 or BRCA2 testing before using Lynparza, or testing of a beneficiary under 18 years of age.
Diagnosis Requirements
In general, the beneficiary must display clinical features or current signs and symptoms of a genetic condition, or there must be a documented reasonable expectation that the beneficiary is high risk based on family history, personal history, or ethnicity.
Age Group Details
For BRCA-related cancers, Medicaid does not cover testing of a beneficiary under 18 years of age.
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
The provider(s) shall submit the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in this policy.
When the provider requests additional units then, in addition to the prior approval requirements noted above, the provider shall submit all of the following supporting documentation to justify the request:
- a. The reason for the test(s);
- b. Previous related lab results;
- c. How the test results contribute to improved health outcomes; and
- d. How the test results alter the beneficiary’s treatment and management.
Conditional Requirements
Prior authorization may be required. Check North Carolina clinical coverage policy 1S-10, Genetic Testing for Carrier and Prenatal for more information
Limits
once in a lifetime
Exclusions
Gene panels are not covered when when the same test is repeated after a negative result, when the test is repeated despite a once-in-a-lifetime limitation, when the test is for beneficiary family members, when the procedure duplicates another provider's procedure, product, or service, or when the procedure is experimental, investigational, or part of a clinical trial. For BRCA-related cancers, Medicaid does not cover repeat BRCA1 or BRCA2 testing before using Lynparza, or testing of a beneficiary under 18 years of age.
Diagnosis Requirements
In general, the beneficiary must display clinical features or current signs and symptoms of a genetic condition, or there must be a documented reasonable expectation that the beneficiary is high risk based on family history, personal history, or ethnicity.
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.