PA Lookup

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 Trillium Health Resources

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

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 per pregnancy

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

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

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

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 per pregnancy

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

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

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

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

Limits

Generally performed at or beyond 14 weeks gestation for genetic testing.

Other procedures performed on the same date of service as amniocentesis are covered if performed by the same provider and billed according to modifier rules.

Other related procedures during the amniocentesis follow-up period, and unrelated procedures during that follow-up period, are covered if performed by the provider who performed the amniocentesis. Amniocentesis is not covered when performed for sex determination without documented risk of an X-linked disorder, or for routine screening without the risk factors listed in the amniocentesis coverage subsection.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

How to Submit

N/A - No authorization is required

Resources

• 1E-4 Fetal Surveillance
• Records Management and Documentation Manual

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

Limits

Chorionic villus sampling is performed during pregnancy at 10 to 12 weeks.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

How to Submit

N/A - No authorization is required

Resources

• 1E-4 Fetal Surveillance
• 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.

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

N/A - No authorization is required

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.

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

N/A - No authorization is required

Resources

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

How to Submit

N/A - No authorization is required

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

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 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

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 per pregnancy

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

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

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

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 per pregnancy

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

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

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

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 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

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

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.

• c. If the Medicaid recipient is under 21 years of age, information supporting

that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

Limits

Generally performed at or beyond 14 weeks gestation for genetic testing.

Other procedures performed on the same date of service as amniocentesis are covered if performed by the same provider and billed according to modifier rules.

Other related procedures during the amniocentesis follow-up period, and unrelated procedures during that follow-up period, are covered if performed by the provider who performed the amniocentesis. Amniocentesis is not covered when performed for sex determination without documented risk of an X-linked disorder, or for routine screening without the risk factors listed in the amniocentesis coverage subsection.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

How to Submit

Please submit your request to Trillium Health Resources

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

Resources

• 1E-4 Fetal Surveillance
• 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

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 per pregnancy

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

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

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

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

Authorization Guidelines

See Evicore site for specific requirements

Reauthorization Guidelines

See Evicore site for specific requirements

Limits

Chorionic villus sampling is performed during pregnancy at 10 to 12 weeks.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1E-4 Fetal Surveillance
• 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

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

Authorization Guidelines

See Evicore site for specific requirements

Reauthorization Guidelines

See Evicore site for specific requirements

Limits

Generally performed at or beyond 14 weeks gestation for genetic testing.

Other procedures performed on the same date of service as amniocentesis are covered if performed by the same provider and billed according to modifier rules.

Other related procedures during the amniocentesis follow-up period, and unrelated procedures during that follow-up period, are covered if performed by the provider who performed the amniocentesis. Amniocentesis is not covered when performed for sex determination without documented risk of an X-linked disorder, or for routine screening without the risk factors listed in the amniocentesis coverage subsection.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

How to Submit

Please submit your request to EviCore

• https://www.evicore.com/

Resources

• 1E-4 Fetal Surveillance
• Records Management and Documentation Manual