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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 : 2.2.6.3 Prior Authorization for BRCA Testing

2.2.6.3
Prior authorization is not required for BRCA large rearrangement gene mutation analysis testing (procedure code 81213) when submitted with a negative test result for procedure code 81211.
Prior authorization is required for initial BRCA testing (procedure codes 81211, 81212, 81214, 81215, 81216, and 81217). The prior authorization request must include documentation that indicates that the client meets one or more of the criteria below:
A female with a personal history of breast cancer, including DCIS, diagnosed at any age and of an ethnicity associated with higher mutation frequency, such as: Ashkenazi Jewish, Icelandic, Swedish, or Hungarian descent
A male or female with a personal history of pancreatic cancer or prostate cancer (Gleason score 7 or greater) at any age regardless of ancestry with at least two close blood relatives with one of the following:
A male or female with a personal history of pancreatic cancer at any age and of an ethnicity associated with higher mutation frequency, such as Ashkenazi Jewish, Icelandic, Swedish, or Hungarian descent and one or more close blood relatives with pancreatic cancer
At least one third degree blood relative who has breast cancer, including DCIS, or ovarian cancer, including fallopian tube and primary peritoneal cancers, and at least two close blood relatives with one of the following:
Note:
The term “close blood relative” includes first-degree male or female relatives (e.g., parents, siblings), second-degree relatives (e.g., aunts, uncles, grandparents), and third-degree relatives (e.g., first cousins, great grandparents), from the same side of the family as the client.
Prior authorization for additional BRCA testing may be considered on a case-by-case basis by Medical Director review when testing criteria for these studies are met for clients who:
Have previously been tested for BRCA1 and BRCA2 comprehensive sequencing gene mutation analysis testing and received negative results. Documentation of negative results for BRCA1 and BRCA2 comprehensive sequencing gene mutation analysis testing are required for medically necessary BRCA large rearrangement gene mutation analysis testing.
Results are not available and every reasonable effort has been made to obtain the results. Documentation of the specific efforts to obtain results from the client’s genetic testing physician or the testing laboratory must be included with the prior authorization request.
BRCA1 and BRCA2 comprehensive sequencing or founder gene mutation analysis testing was obtained and interpreted before BRCA large rearrangement gene mutation analysis testing (procedure code 81213) was available.
A completed Hereditary Breast and Ovarian Cancer (HBOC) Genetic Testing Prior Authorization Request Form that has been signed and dated by the referring provider must be submitted.
A provider’s signature on a submitted document indicates that the provider certifies, to the best of the provider’s knowledge, the information in the document is true, accurate, and complete.
For comprehensive sequencing, the physician must indicate one of the following on the prior authorization request form:
The client’s familial genetic history that supports medical necessity for the requested BRCA1 and BRCA2 comprehensive sequencing, founder gene mutation analysis, or known familial variant gene mutation analysis testing.
Every reasonable effort was made to obtain the client’s familial genetic history and have been unable to obtain BRCA1 and BRCA2 comprehensive sequencing gene mutation analysis testing results for the affected family member(s). Documentation of the specific efforts made to obtain the client’s familial genetic history must be submitted with the request.
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. Medical documentation that is submitted by the physician must verify 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 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.
A request for retroactive authorization must be submitted no later than seven calendar days beginning the day after the lab draw is performed.

Texas Medicaid & Healthcare Partnership
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