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26.4.13 Breast Cancer (BRCA)
26.4.13.1 BRCA Testing
Gene mutation analyses (procedure codes 5-S3820, 5-S3822, and 5-S3823) are benefits of the Texas Medicaid Program.
Breast cancer 1 (BRCA1) and breast cancer 2 (BRCA2) are responsible for keeping breast cells from growing too rapidly or in an uncontrolled way. Mutations within the gene interrupt this regulatory function and increase the risk of breast cancer.
Note: Guidelines for BRCA mutation testing are based on guidelines established by the U.S. Preventative Services Task Force.
The procedure codes that describe the three basic steps of testing for a BRCA mutation, b-hexasominidase (procedure code 5-83080), isolation and separation of DNA (procedure codes 5-83890, 5-83891, 5-83892, 5-83893, 5-83894, 5-83896, and 5-83897), molecular diagnostics (procedure codes 5-83898, 5-83900, 5-83901, 5-83902, 5-83907, 5-83908, 5-83909, and 5-83912), and mutation scanning or identification (procedure codes 5-83903, 5-83904, 5-83905, and 5-83906) are not a benefit for the following breast cancer diagnosis codes:
BRCA1 and BRCA2 (procedure codes 5-S3820, 5-S3822, and 5-S3823) are limited to once per lifetime. Additional services may be considered on appeal.
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