PA Lookup

Next-generation sequencing, also referred to as next-gen sequencing, has revolutionized genetic research and healthcare by enabling the identification of genetic variations. This innovative technique involves determining the sequence of nucleotides, the building blocks of DNA, in a beneficiary’s genetic code, which is known as DNA sequencing. Two commonly employed methods, namely whole exome sequencing and whole genome sequencing, leverage advanced technologies that enable the rapid sequencing of substantial amounts of DNA. These approaches have significantly propelled the field of genetics and serve as invaluable tools in the detection of genetic disorders.

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 each primary cancer occurrence

Age Group Details

Comparator genome sequence analysis is limited to beneficiaries 21 years of age and younger, Whole genome sequencing requires beneficiary to be 21 years of age or younger.

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1S-12, Genetic Testing - Next Generation Sequencing (NGS)
• Records Management and Documentation Manual

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

• https://www.evicore.com/

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

• https://www.evicore.com/

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

• https://www.evicore.com/

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

• https://www.evicore.com/

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

• https://www.evicore.com/

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

• https://www.evicore.com/

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

• https://www.evicore.com/

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

• https://www.evicore.com/

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

• https://www.evicore.com/

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 per pregnancy

Place of Service

Inpatient, Outpatient, Office, Laboratory

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1S-10, Genetic Testing for Diagnosis and Treatment
• Records Management and Documentation Manual

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 per pregnancy

Place of Service

Inpatient, Outpatient, Office, Laboratory

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1S-10, Genetic Testing for Diagnosis and Treatment
• Records Management and Documentation Manual

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 per pregnancy

Place of Service

Inpatient, Outpatient, Office, Laboratory

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1S-10, Genetic Testing for Diagnosis and Treatment
• Records Management and Documentation Manual

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 per pregnancy

Place of Service

Inpatient, Outpatient, Office, Laboratory

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1S-10, Genetic Testing for Diagnosis and Treatment
• Records Management and Documentation Manual

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 per pregnancy

Place of Service

Inpatient, Outpatient, Office, Laboratory

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1S-10, Genetic Testing for Diagnosis and Treatment
• Records Management and Documentation Manual

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 per pregnancy

Place of Service

Inpatient, Outpatient, Office, Laboratory

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1S-10, Genetic Testing for Diagnosis and Treatment
• Records Management and Documentation Manual

Gene expression refers to the mechanism through which the genetic information stored in a gene is transformed into a functional outcome. This predominantly transpires by transcribing RNA molecules that encode proteins or non-coding RNA molecules with alternative roles. Gene expression can be likened to an "on off switch," determining the timing and location of RNA molecules and proteins production, and a "volume control," dictating the quantity of these products generated. The process of gene expression is meticulously regulated and undergoes significant changes based on various conditions and cell types. Numerous RNA and protein products derived from genes play a role in governing the expression of other genes. The extent, timing, and manner in which a gene is expressed can be evaluated by assessing the functional activity of its product or observing the phenotype associated with the gene

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 each primary cancer occurrence

Exclusions

Breast cancer gene expression profiling is not covered when CCP Specific criteria are not met or when used to predict response to specific chemotherapy regimens, for known metastatic cancer, for ductal carcinoma in situ when DCIS is the sole breast cancer histology, for the same tumor or more than one site when the primary tumor is multifocal, or to determine risk after the beneficiary has already decided to undergo or forego chemotherapy. Breast cancer management testing is also not covered when a gene expression profiling test other than the specified covered assays is used.

Thyroid nodule gene expression profiling is not covered when the additional criteria in the CCP are not met.

AlloMap is not covered for beneficiaries with a history of antibody-mediated rejection, for uses outside heart transplant rejection monitoring, or when results would not affect clinical management such as when a biopsy is already planned based on other risk factors.

Age Group Details

Thyroid nodule gene expression profiling is limited to beneficiaries age 21 years and older.

AlloMap molecular expression testing is limited to beneficiaries age 15 years and older.

Place of Service

Inpatient, Outpatient, Office, Laboratory.

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1S-11, Genetic Testing for Diagnosis and Treatment
• Records Management and Documentation Manual

Gene expression refers to the mechanism through which the genetic information stored in a gene is transformed into a functional outcome. This predominantly transpires by transcribing RNA molecules that encode proteins or non-coding RNA molecules with alternative roles. Gene expression can be likened to an "on off switch," determining the timing and location of RNA molecules and proteins production, and a "volume control," dictating the quantity of these products generated. The process of gene expression is meticulously regulated and undergoes significant changes based on various conditions and cell types. Numerous RNA and protein products derived from genes play a role in governing the expression of other genes. The extent, timing, and manner in which a gene is expressed can be evaluated by assessing the functional activity of its product or observing the phenotype associated with the gene

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 each primary cancer occurrence

Exclusions

Breast cancer gene expression profiling is not covered when CCP Specific criteria are not met or when used to predict response to specific chemotherapy regimens, for known metastatic cancer, for ductal carcinoma in situ when DCIS is the sole breast cancer histology, for the same tumor or more than one site when the primary tumor is multifocal, or to determine risk after the beneficiary has already decided to undergo or forego chemotherapy. Breast cancer management testing is also not covered when a gene expression profiling test other than the specified covered assays is used.

Thyroid nodule gene expression profiling is not covered when the additional criteria in the CCP are not met.

AlloMap is not covered for beneficiaries with a history of antibody-mediated rejection, for uses outside heart transplant rejection monitoring, or when results would not affect clinical management such as when a biopsy is already planned based on other risk factors.

Age Group Details

Thyroid nodule gene expression profiling is limited to beneficiaries age 21 years and older.

AlloMap molecular expression testing is limited to beneficiaries age 15 years and older.

Place of Service

Inpatient, Outpatient, Office, Laboratory.

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1S-11, Genetic Testing for Diagnosis and Treatment
• Records Management and Documentation Manual

Gene expression refers to the mechanism through which the genetic information stored in a gene is transformed into a functional outcome. This predominantly transpires by transcribing RNA molecules that encode proteins or non-coding RNA molecules with alternative roles. Gene expression can be likened to an "on off switch," determining the timing and location of RNA molecules and proteins production, and a "volume control," dictating the quantity of these products generated. The process of gene expression is meticulously regulated and undergoes significant changes based on various conditions and cell types. Numerous RNA and protein products derived from genes play a role in governing the expression of other genes. The extent, timing, and manner in which a gene is expressed can be evaluated by assessing the functional activity of its product or observing the phenotype associated with the gene

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 each primary cancer occurrence

Exclusions

Breast cancer gene expression profiling is not covered when CCP Specific criteria are not met or when used to predict response to specific chemotherapy regimens, for known metastatic cancer, for ductal carcinoma in situ when DCIS is the sole breast cancer histology, for the same tumor or more than one site when the primary tumor is multifocal, or to determine risk after the beneficiary has already decided to undergo or forego chemotherapy. Breast cancer management testing is also not covered when a gene expression profiling test other than the specified covered assays is used.

Thyroid nodule gene expression profiling is not covered when the additional criteria in the CCP are not met.

AlloMap is not covered for beneficiaries with a history of antibody-mediated rejection, for uses outside heart transplant rejection monitoring, or when results would not affect clinical management such as when a biopsy is already planned based on other risk factors.

Age Group Details

Thyroid nodule gene expression profiling is limited to beneficiaries age 21 years and older.

AlloMap molecular expression testing is limited to beneficiaries age 15 years and older.

Place of Service

Inpatient, Outpatient, Office, Laboratory.

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1S-11, Genetic Testing for Diagnosis and Treatment
• Records Management and Documentation Manual

Gene expression refers to the mechanism through which the genetic information stored in a gene is transformed into a functional outcome. This predominantly transpires by transcribing RNA molecules that encode proteins or non-coding RNA molecules with alternative roles. Gene expression can be likened to an "on off switch," determining the timing and location of RNA molecules and proteins production, and a "volume control," dictating the quantity of these products generated. The process of gene expression is meticulously regulated and undergoes significant changes based on various conditions and cell types. Numerous RNA and protein products derived from genes play a role in governing the expression of other genes. The extent, timing, and manner in which a gene is expressed can be evaluated by assessing the functional activity of its product or observing the phenotype associated with the gene

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 each primary cancer occurrence

Exclusions

Breast cancer gene expression profiling is not covered when CCP Specific criteria are not met or when used to predict response to specific chemotherapy regimens, for known metastatic cancer, for ductal carcinoma in situ when DCIS is the sole breast cancer histology, for the same tumor or more than one site when the primary tumor is multifocal, or to determine risk after the beneficiary has already decided to undergo or forego chemotherapy. Breast cancer management testing is also not covered when a gene expression profiling test other than the specified covered assays is used.

Thyroid nodule gene expression profiling is not covered when the additional criteria in the CCP are not met.

AlloMap is not covered for beneficiaries with a history of antibody-mediated rejection, for uses outside heart transplant rejection monitoring, or when results would not affect clinical management such as when a biopsy is already planned based on other risk factors.

Age Group Details

Thyroid nodule gene expression profiling is limited to beneficiaries age 21 years and older.

AlloMap molecular expression testing is limited to beneficiaries age 15 years and older.

Place of Service

Inpatient, Outpatient, Office, Laboratory.

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1S-11, Genetic Testing for Diagnosis and Treatment
• Records Management and Documentation Manual