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36.4.9.13 Breast Cancer (BRCA)
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.
Prior authorization is required for gene mutation analysis. For non-Ashkenazi Jewish women, there must be documentation of one or more of the following:
• 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 age 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, there must be documentation of an increased risk due to family history. An increased risk includes any first-degree relative (or second-degree relatives on the same side of the family) with breast or ovarian cancer.
A written 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 are not accepted. The original signature copy must be kept in the physician's medical record for the client.
To complete the prior authorization process, the provider must mail or fax the request to the TMHP Special Medical Prior Authorization Unit and include documentation of medical necessity.
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.
Interpretation of gene mutation analysis results is not separately reimbursable. Interpretation is part of the physician E/M service.
The following procedure codes which describe the three basic steps for testing for a BRCA mutation are not considered for reimbursement when submitted with a breast cancer diagnosis code (1740, 1741, 1742, 1743, 1744, 1745, 1746, 1748, 1749, 1750, 1759, 1982, 19881, and 2330):
•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).
•Mutation scanning or identification (procedure codes 5-83903, 5-83904, 5-83905, and 5-83906).
Claims filed using these procedure codes with a diagnosis of breast cancer may be reviewed on appeal.
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.
Prognostic Breast and Gynecological Cancer Studies
Prognostic breast and gynecological cancer studies are benefits of the Texas Medicaid Program when ordered by a physician for the purpose of determining the best course of treatment for a patient with breast/gynecological cancers.
Prognostic breast and gynecological cancer studies are divided into two categories: Receptor assays and Her-2/neu.
•Receptor Assays (procedure codes 5-84233 and 5-84234) - The estrogen receptor assay (ERA) and the progesterone receptor assay (PRA) are tests in which a tissue sample is exposed to radioactively tagged estrogen or progesterone. The presence of these receptors can have prognostic significance in breast and edometrial cancer.
•Her-2/neu (procedure codes 5-83890, 5-88237, 5-88239, 5-88271, 5-88274, 5-88291, 5-88342, 5-88360, 5-88361 and 5-88365) - Human epidermal growth factor receptor 2 (Her-2/neu) is responsible for the production of a protein that signals cell growth. The over-expression of Her-2/neu in breast cancer is associated with decreased overall survival and response to some therapies. Each procedure used in the analysis should be coded separately.
Reimbursement for receptor assays (procedure codes 5-84233, 5-84234, 5-88360, and 5-88361) are limited to claims with a diagnosis of breast or uterine cancer as listed in the following table. Receptor testing for other diagnoses will be denied.
Interpretation of receptor assays, and Her-2/neu results is not considered separately for reimbursement. Interpretation is part of the physician's E/M service.
Gene mutation analyses (procedure codes 5-S3820, 5-S3822, and 5-S3823) are not considered for reimbursement when submitted with the same date of service as the following procedure codes:
Claims filed using these procedure codes may be considered upon appeal.
The following procedure codes are limited to once per lifetime:
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