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December 2016 Texas Medicaid Provider Procedures Manual

Radiology and Laboratory Services Handbook : 2 Independent Laboratory : 2.2 Services, Benefits, Limitations, and Prior Authorization : 2.2.6 Breast Cancer Gene 1 and 2 (BRCA) Testing

Breast Cancer Gene 1 and 2 (BRCA) testing services are benefits of Texas Medicaid when billed with the following procedure codes:
Breast cancer gene 1, early onset (BRCA1) and breast cancer gene 2, susceptibility protein (BRCA2) are tumor repressor genes 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 and ovarian cancer, have been linked to other types of cancer such as pancreatic and prostate, and can be inherited from a person’s mother or father.
Coverage of BRCA mutation analysis testing, including large rearrangement gene mutation analysis testing, are based on the National Comprehensive Cancer Network (NCCN) guidelines.
Interpretation of gene mutation analysis results is not separately reimbursable. Interpretation is part of the physician E/M service.
BRCA gene mutation analysis testing must be ordered based on familial medical history and the availability of previous familial gene mutation analysis testing results and only if the test results will affect treatment decisions or provide prognostic information.
Unaffected male or females with a family history of breast cancer, including diagnosis of ductal carcinoma in situ (DCIS), should only be considered for testing when the appropriate affected family member is unavailable. Clinical judgment should be used to determine if the client has a reasonable likelihood of a mutation, considering the client’s current age and the age of the unaffected female relatives who link the client with the affected relatives.
It is mandatory that a client who is at risk for BRCA1, BRCA2, or BRCA large rearrangement genetic mutation receive genetic counseling before and after BRCA gene mutation testing.
BRCA gene mutation analysis testing (procedure codes 81162, 81211, 81212, 81213, 81214, 81215, 81216, and 81217) is limited to once per lifetime. Additional testing services may be considered for BRCA1 and BRCA2 comprehensive sequencing gene mutation analysis testing (procedure code 81211) on a case-by-case basis with prior authorization.

Texas Medicaid & Healthcare Partnership
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