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26.4.13.2 Authorization Requirements
Prior authorization is required for gene mutation analysis (procedure codes 5-S3820, 5-S3822, and 5-S3823). There must be documentation of one or more of the following:
• For non-Ashkenazi Jewish women, these patterns include:
•Two first-degree relatives with breast cancer, one of whom was diagnosed at age 50 or younger
•A combination of three or more first- or second-degree relatives with breast cancer, regardless of age of diagnosis.
•A combination of both breast and ovarian cancer among first- and second-degree relatives with ovarian cancer.
•A first-degree relative with bilateral breast cancer.
•A combination of two or more first- or second-degree relatives with ovarian cancer, regardless of diagnosis.
•A first-or second-degree relative with both breast and ovarian cancer, at any age.
•A history of breast cancer in a male relative.
•For women of Ashkenazi Jewish heritage, an increased-risk family history includes any first- or second-degree relative on the same side of the family with breast or ovarian cancer.
A written prior authorization request, signed and dated by the referring provider, must be submitted. All signatures must be current, unaltered, original and handwritten. Computerized or stamped signatures will not be accepted. The original signature copy must be kept in the physician's medical record for the client.
To complete the prior authorization process, a provider must send the request to the TMHP Special Medical Prior Authorization unit and include documentation of medical necessity. The request can be faxed to 1-512-514-4213 or mailed to:
Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization Department
12357-B Riata Trace Parkway, Suite 150
Austin, TX 78727
To facilitate a determination of medical necessity and avoid unnecessary denials, the physician must provide correct and complete information, including accurate medical necessity of the services requested.
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