Effective 9/1/24: Genetic Services Biomarker Testing
Date: 08/16/24
Effective for dates of service on or after September 1, 2024, certain genetic services testing procedure codes 81279, 81305, 81307, 81320, 81345, 81425, 81426, 81427, 81443 will become a benefit of Texas Medicaid and will be limited to one service per lifetime to any provider.
As a result of this benefit update Superior HealthPlan will require prior authorization for procedure codes 81307, 81425, 81426, 81427, 81443 for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP members.
Prior authorization requests for members of all ages should be submitted to Evolent’s website, by calling 1-800-642-7554 or faxing to 1-800-784-6864.
Superior ensures medical necessity review criteria is current and appropriate for members and the scope of services provided. As a result, the following procedure code update is effective on September 1, 2024.
CPT Code | CPT Description | Criteria |
81307 | PALB2 (partner and localizer of BRCA2) (e.g., breast and pancreatic cancer) gene analysis; full gene sequence |
Evolent’s genetic testing clinical guidelines that will be utilized for these services can be found on Evolent’s Genetic Testing Solutions webpage.
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81425 | Genome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis | |
81426 | Genome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (e.g., parents, siblings) (List separately in addition to code for primary procedure) | |
81427 | Genome (e.g., unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained genome sequence (e.g., updated knowledge or unrelated condition/syndrome) | |
81443 | Genetic testing for severe inherited conditions (e.g., cystic fibrosis, Ashkenazi Jewish-associated disorders [e.g., Bloom syndrome, Canavan disease, Fanconi anemia type C, mucolipidosis type VI, Gaucher disease, Tay-Sachs disease], beta hemoglobinopathies, phenylketonuria, galactosemia), genomic sequence analysis panel, must include sequencing of at least 15 genes (e.g., ACADM, ARSA, ASPA, ATP7B, BCKDHA, BCKDHB, BLM, CFTR, DHCR7, FANCC, G6PC, GAA, GALT, GBA, GBE1, HBB, HEXA, IKBKAP, MCOLN1, PAH) |
To review Evolent’s prior authorization requirements, please visit Evolent's website.
For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.