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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 8. Physician : 8.2 Services, Benefits, Limitations, and Prior Authorization : 8.2.14 BRCA Testing : 8.2.14.1 Prior Authorization for Gene Mutation Analysis

8.2.14.1
Prior authorization is required for gene mutation analysis (procedure codes S3820, S3822, S3823, 81211, 81212, 81214, 81215, 81216, and 81217). The prior authorization request must include documentation that meets one or more of the criteria below:
Two first-degree or second-degree relatives with epithelial ovarian or breast cancer who were 50 years of age and younger when they were diagnosed with breast cancer, or were any age when they were diagnosed with epithelial ovarian cancer
One or more first- or second-degree relatives with epithelial ovarian cancer and one or more first- or second-degree relatives with breast cancer at any age
Multiple primary or bilateral breast cancers in a single individual and another first- or second-degree relative diagnosed with breast cancer at 50 years of age or younger
Breast cancer or epithelial ovarian cancer at any age and are at increased risk for specific mutations due to ethnic background (for example, Ashkenazi Jewish descent)
Two primary breast cancers in a single individual with at least one relative who was diagnosed with breast cancer at 50 years of age or younger
Ashkenazi Jewish descent, or other ethnic descent associated with deleterious mutations (for example, populations of Icelandic, Swedish, Hungarian or other), with or without family history
Note:
The term “relative” means close blood relatives including first-degree male or female relatives (e.g., parents, siblings, children), second-degree relatives (e.g., aunts, uncles, grandparents, nieces, nephews), and third-degree relatives (e.g., first cousin, great grandparent), all of whom are on the same side of the family as the client.
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 provider’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.
The medical record must include documentation of formal pretest counseling, including an assessment of the client’s ability to understand the risks and limitations of the test and the client’s informed choice to proceed with testing for the BRCA1 and BRCA2 mutations. The medical record is subject to retrospective review.
The medical record documentation that is submitted by the provider must establish the client’s diagnosis or family history. Requisition forms from the laboratory are not sufficient for the establishment of a client’s personal and family history.
To facilitate a determination of medical necessity and avoid unnecessary denials, the provider must provide correct and complete information, including accurate medical necessity of the services requested.

Texas Medicaid & Healthcare Partnership
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