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Gene Expression Profiling Procedure Code 81520 to Become a Benefit Effective April 1, 2022

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after April 1, 2022, gene expression profiling procedure code 81520 will become a benefit of Texas Medicaid.

Procedure code 81520 will be a benefit when all the following criteria are met:

  • The clinical stage of the breast cancer is I or II, and the cancer has not spread to more than three lymph nodes.
  • The primary tumor is hormone receptor positive.
  • The client is female and post-menopausal.

Procedure code 81520 may be reimbursed for female clients of all ages who meet the above criteria to physician providers for services rendered in the office setting, to hospital providers in the outpatient hospital setting, and to independent laboratory providers in the laboratory setting.

Procedure code 81520 may be reimbursed once per lifetime, any procedure, any provider, when submitted with one of the following diagnosis codes:

Diagnosis Codes

C50011

C50012

C50111

C50112

C50211

C50212

C50311

C50312

C50411

C50412

C50511

C50512

C50611

C50612

C50811

C50812

C50911

C50912

D0501

D0502

D0511

D0512

D0581

D0582

Z170

         

Procedure codes 81519 and 81520 may be reimbursed more than once per lifetime for the same client on appeal, if the provider submits documentation demonstrating that the client has a new, second primary breast cancer diagnosis.

Updated Criteria for Procedure Code 81519

Procedure code 81519 is a benefit when all the following criteria are met:

  • The clinical stage of the breast cancer is I, II, or IIIa, and the cancer has not spread to more than three lymph nodes.
  • The primary tumor is estrogen receptor positive and Her-2/neu receptor negative, or the primary tumor is Her-2/neu receptor positive and less than 1 cm in diameter.
  • The client is a candidate for adjuvant chemotherapy.
  • The outcome of the test will guide decision-making regarding adjuvant chemotherapy.

For more information, call the Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at 800-925-9126.