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Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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12437 Results

PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant

Service Code
81322 (CPT) PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant

Service Code
81323 (CPT) PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis

Service Code
81325 (CPT) PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant

Service Code
81326 (CPT) PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

SEPT9 (Septin9) (eg, colorectal cancer) promoter methylation analysis

Service Code
81327 (CPT) SEPT9 (Septin9) (eg, colorectal cancer) promoter methylation analysis
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg, *5)

Service Code
81328 (CPT) SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg, *5)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Genetic Testing for Diagnosis and Treatment

Service Code
81329 (CPT) SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing), includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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

Service Code
81329 (CPT) SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing), includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

Genetic Testing for Diagnosis and Treatment

Service Code
81331 (CPT) SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (eg, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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

Service Code
81332 (CPT) SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase, antitrypsin, member 1) (eg, alpha-1-antitrypsin deficiency), gene analysis, common variants (eg, *S and *Z)
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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

TGFBI (transforming growth factor beta-induced) (eg, corneal dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L, R555W, R555Q)

Service Code
81333 (CPT) TGFBI (transforming growth factor beta-induced) (eg, corneal dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L, R555W, R555Q)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Genetic Testing for Diagnosis and Treatment

Service Code
81334 (CPT) RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analysis (eg, exons 3-8)
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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

TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3)

Service Code
81335 (CPT) TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Genetic Testing for Diagnosis and Treatment

Service Code
81336 (CPT) SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; full gene sequence
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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 Carrier and Clinical Coverage Policy No:1S-10 Prenatal

Service Code
81336 (CPT) SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; full gene sequence
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

See Evicore site for specific requirements

Reauthorization Guidelines

See Evicore site for specific requirements

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

Please submit your request to EviCore

Resources

Genetic Testing for Diagnosis and Treatment

Service Code
81337 (CPT) SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familial sequence variant(s)
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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 Carrier and Clinical Coverage Policy No:1S-10 Prenatal

Service Code
81337 (CPT) SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familial sequence variant(s)
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

See Evicore site for specific requirements

Reauthorization Guidelines

See Evicore site for specific requirements

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

Please submit your request to EviCore

Resources

Genetic Testing for Diagnosis and Treatment

Service Code
81338 (CPT) MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; common variants (eg, W515A, W515K, W515L, W515R)
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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

Service Code
81339 (CPT) MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; sequence analysis, exon 10
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

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

TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (eg, polymerase chain reaction)

Service Code
81340 (CPT) TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (eg, polymerase chain reaction)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore