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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 : 2.2.10 Genetic Testing for Colorectal Cancer

Genetic testing is provided to clients who have a first- or second-degree relative who has or has had colorectal cancer in order to determine if the client may have increased risk for developing colorectal cancer.
A first-degree relative is defined as: sibling, parent, or offspring. A second-degree relative is defined as: uncle, aunt, grandparent, nephew, niece, or half-sibling.
Interpretation of gene mutation analysis results are part of the evaluation and management service and will not be reimbursed separately.
Genetic test results, when informative, may influence clinical management decisions. The documentation that is maintained in the client’s medical record must reflect that the client or family member has been given information on the nature, inheritance, and implications of genetic disorders to help them make informed medical and personal decisions prior to the genetic testing. The testing must be medically necessary and supported by documentation with a clear rationale for testing, which must be retained in the client’s medical record and made available upon request.

Texas Medicaid & Healthcare Partnership
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