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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 : 2.2.10.2 Authorization Requirements

2.2.10.2
Prior authorization is required for gene mutation analysis. Prior authorized services may be reimbursed once per lifetime when billed by any provider. Additional services will not be prior authorized.
Prior authorization requests may be considered for Familial Adenomatous Polyposis (FAP) testing for clients of any age with well defined hereditary cancer syndromes and for which either a positive or negative result will change medical care. The client for whom the request is made must have more than 20 polyps or a first-degree relative with FAP and a documented mutation.
Note:
Clients who are seven years of age or younger must have clear rationale for testing and documentation of medical necessity from the client’s medical record must be submitted with the prior authorization request.
Prior authorization requests may be considered for Hereditary Nonpolyposis Colorectal Cancer (HNPCC) testing for clients of any age. Testing for HNPCC is used to determine whether an individual has an increased risk for colorectal cancer or other HNPCC-associated cancers. Results of the test may influence clinical management decisions. The request must include one or more of the following criteria for testing:
The client has three or more family members (at least one must be a first-degree relative) who have colorectal cancer, and FAP has been ruled out. Two successive generations were affected, and one or more of the relatives was diagnosed with colorectal cancer at 50 years of age or younger.
The client has colorectal cancer and a first-degree relative who also has colorectal cancer or HNPCC extracolonic cancer at 50 years of age or younger or colorectal adenoma at 40 years of age or younger.
Note:
Clients who are 20 years of age or younger must have clear rationale for testing and documentation of medical necessity from the client’s medical record must be submitted with the prior authorization request.
A provider’s signature, including the prescribing provider’s, 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.
Requisition forms from the laboratory are not sufficient for verification of the personal and family history.
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.
Guidelines for MLH1 and MLH2 mutation testing are based on guidelines established by the American College of Medical Genetics and the American Gastroenterological Association.
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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