PA Lookup

If you have questions about prior authorizations, please call:

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

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

Filter By:
Clear Filters
12437 Results

PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions

Service Code
0235U (CPT) PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

How to Submit

Please submit your request to EviCore

SMN1 (survival of motor neuron 1, telomeric) and SMN2 (survival of motor neuron 2, centromeric) (eg, spinal muscular atrophy) full gene analysis, including small sequence changes in exonic and intronic regions, duplications, deletions, and mobile element insertions

Service Code
0236U (CPT) SMN1 (survival of motor neuron 1, telomeric) and SMN2 (survival of motor neuron 2, centromeric) (eg, spinal muscular atrophy) full gene analysis, including small sequence changes in exonic and intronic regions, duplications, deletions, and mobile element insertions
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

How to Submit

Please submit your request to EviCore

Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia), genomic sequence analysis panel including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions

Service Code
0237U (CPT) Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia), genomic sequence analysis panel including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

How to Submit

Please submit your request to EviCore

Genetic Testing for Diagnosis and Treatment

Service Code
0238U (CPT) Oncology (Lynch syndrome), genomic DNA sequence analysis of MLH1, MSH2, MSH6, PMS2, and EPCAM, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regio
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.

Authorization Guidelines

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

Reauthorization Guidelines

See Evicore site for specific requirements

Limits

once in a lifetime

Place of Service

Inpatient, Outpatient, Office, Laboratory

How to Submit

Please submit your request to EviCore

Resources

1S-12, Genetic Testing - Next Generation Sequencing (NGS)

Service Code
0239U (CPT) Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, insertions, deletions, select rearrangements, and copy number variations
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

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

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

Resources

1S-12, Genetic Testing - Next Generation Sequencing (NGS)

Service Code
0242U (CPT) Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

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

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

Resources

1S-12, Genetic Testing - Next Generation Sequencing (NGS)

Service Code
0244U (CPT) Oncology (solid organ), DNA, comprehensive genomic profiling, 257 genes, interrogation for single-nucleotide variants, insertions/deletions, copy number alterations, gene rearrangements, tumor-mutational burden and microsatellite instability, utilizing fo
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

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

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

Resources

Genetic Testing - Gene Expression

Service Code
0245U (CPT) Oncology (thyroid), mutation analysis of 10 genes and 37 RNA fusions and expression of 4 mRNA markers using next-generation sequencing, fine needle aspirate, report includes associated risk of malignancy expressed as a percentage
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

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

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

Resources

Red blood cell antigen typing, DNA, genotyping of at least 16 blood groups with phenotype prediction of at least 51 red blood cell antigens

Service Code
0246U (CPT) Red blood cell antigen typing, DNA, genotyping of at least 16 blood groups with phenotype prediction of at least 51 red blood cell antigens
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

How to Submit

Please submit your request to EviCore

1S-12, Genetic Testing - Next Generation Sequencing (NGS)

Service Code
0250U (CPT) Oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes, interrogation for somatic alterations (SNVs [single nucleotide variant], small insertions and deletions, one amplification, and four translocations), microsatellite inst
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

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

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

Resources

Hepcidin-25, enzyme-linked immunosorbent assay (ELISA), serum or plasma

Service Code
0251U (CPT) Hepcidin-25, enzyme-linked immunosorbent assay (ELISA), serum or plasma
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

How to Submit

N/A - No authorization is required

Fetal aneuploidy short tandem-repeat comparative analysis, fetal DNA from products of conception, reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplication, mosaicism, and segmental aneuploidy

Service Code
0252U (CPT) Fetal aneuploidy short tandem-repeat comparative analysis, fetal DNA from products of conception, reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplication, mosaicism, and segmental aneuploidy
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

How to Submit

Please submit your request to EviCore

Reproductive medicine (endometrial receptivity analysis), RNA gene expression profile, 238 genes by next-generation sequencing, endometrial tissue, predictive algorithm reported as endometrial window of implantation (eg, pre-receptive, receptive, post-receptive)

Service Code
0253U (CPT) Reproductive medicine (endometrial receptivity analysis), RNA gene expression profile, 238 genes by next-generation sequencing, endometrial tissue, predictive algorithm reported as endometrial window of implantation (eg, pre-receptive, receptive, post-receptive)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

How to Submit

Please submit your request to EviCore

Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using embryonic DNA genomic sequence analysis for aneuploidy, and a mitochondrial DNA score in euploid embryos, results reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplication, mosaicism, and segmental aneuploidy, per embryo tested

Service Code
0254U (CPT) Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using embryonic DNA genomic sequence analysis for aneuploidy, and a mitochondrial DNA score in euploid embryos, results reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplication, mosaicism, and segmental aneuploidy, per embryo tested
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

How to Submit

Please submit your request to EviCore

Andrology (infertility), sperm-capacitation assessment of ganglioside GM1 distribution patterns, fluorescence microscopy, fresh or frozen specimen, reported as percentage of capacitated sperm and probability of generating a pregnancy score

Service Code
0255U (CPT) Andrology (infertility), sperm-capacitation assessment of ganglioside GM1 distribution patterns, fluorescence microscopy, fresh or frozen specimen, reported as percentage of capacitated sperm and probability of generating a pregnancy score
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

How to Submit

N/A - No authorization is required

Very long chain acyl-coenzyme A (CoA) dehydrogenase (VLCAD), leukocyte enzyme activity, whole blood

Service Code
0257U (CPT) Very long chain acyl-coenzyme A (CoA) dehydrogenase (VLCAD), leukocyte enzyme activity, whole blood
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

How to Submit

N/A - No authorization is required

Autoimmune (psoriasis), mRNA, next-generation sequencing, gene expression profiling of 50-100 genes, skin-surface collection using adhesive patch, algorithm reported as likelihood of response to psoriasis biologics

Service Code
0258U (CPT) Autoimmune (psoriasis), mRNA, next-generation sequencing, gene expression profiling of 50-100 genes, skin-surface collection using adhesive patch, algorithm reported as likelihood of response to psoriasis biologics
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

How to Submit

Please submit your request to EviCore

Nephrology (chronic kidney disease), nuclear magnetic resonance spectroscopy measurement of myo-inositol, valine, and creatinine, algorithmically combined with cystatin C (by immunoassay) and demographic data to determine estimated glomerular filtration r

Service Code
0259U (CPT) Nephrology (chronic kidney disease), nuclear magnetic resonance spectroscopy measurement of myo-inositol, valine, and creatinine, algorithmically combined with cystatin C (by immunoassay) and demographic data to determine estimated glomerular filtration r
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

How to Submit

N/A - No authorization is required

Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping

Service Code
0260U (CPT) Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

How to Submit

Please submit your request to EviCore

Oncology (solid tumor), gene expression profiling by real-time RT-PCR of 7 gene pathways (ER, AR, PI3K, MAPK, HH, TGFB, Notch), formalin-fixed paraffin-embedded (FFPE), algorithm reported as gene pathway activity score

Service Code
0262U (CPT) Oncology (solid tumor), gene expression profiling by real-time RT-PCR of 7 gene pathways (ER, AR, PI3K, MAPK, HH, TGFB, Notch), formalin-fixed paraffin-embedded (FFPE), algorithm reported as gene pathway activity score
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

How to Submit

Please submit your request to EviCore