PA Lookup

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

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

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

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

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

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

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

Therapeutic Abortion A therapeutic abortion is the termination of a pregnancy where fetal heart tones are present at the time of the abortive procedure. The termination of a pregnancy may be induced medically (prostaglandin suppositories, etc.) or surgically (dilation and curettage, etc.). This includes the delivery of a non-viable (incapable of living outside the uterus) but live fetus, if labor was augmented by pitocin drip, laminaria suppository, etc.

Non-Therapeutic Abortion A non-therapeutic abortion is any termination of a pregnancy where there has been no manual or surgical interruption of that pregnancy (missed, incomplete, spontaneous, etc.).

Limits

A non-therapeutic abortion is defined as termination of a pregnancy where there has been no manual or surgical interruption of the pregnancy, such as missed, incomplete, or spontaneous abortion. Medicaid covers non-therapeutic abortions when the procedure is medically necessary and provided in accordance with federal and state laws and regulations. Specific coverage for non-therapeutic abortion applies when the termination of pregnancy occurs without any manual or surgical interruption of that pregnancy, including missed, incomplete, and spontaneous abortions.

Place of Service

Inpatient, Outpatient Hospital, Office

How to Submit

N/A - No authorization is required

Resources

• 1E-2 Therapeutic and Non-therapeutic Abortions
• Records Management and Documentation Manual

Therapeutic Abortion A therapeutic abortion is the termination of a pregnancy where fetal heart tones are present at the time of the abortive procedure. The termination of a pregnancy may be induced medically (prostaglandin suppositories, etc.) or surgically (dilation and curettage, etc.). This includes the delivery of a non-viable (incapable of living outside the uterus) but live fetus, if labor was augmented by pitocin drip, laminaria suppository, etc.

Non-Therapeutic Abortion A non-therapeutic abortion is any termination of a pregnancy where there has been no manual or surgical interruption of that pregnancy (missed, incomplete, spontaneous, etc.).

Limits

A non-therapeutic abortion is defined as termination of a pregnancy where there has been no manual or surgical interruption of the pregnancy, such as missed, incomplete, or spontaneous abortion. Medicaid covers non-therapeutic abortions when the procedure is medically necessary and provided in accordance with federal and state laws and regulations. Specific coverage for non-therapeutic abortion applies when the termination of pregnancy occurs without any manual or surgical interruption of that pregnancy, including missed, incomplete, and spontaneous abortions.

Place of Service

Inpatient, Outpatient Hospital, Office

How to Submit

N/A - No authorization is required

Resources

• 1E-2 Therapeutic and Non-therapeutic Abortions
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required