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Genetic Services Biomarker Testing Benefits for Texas Medicaid Effective September 1, 2024

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

On September 1, 2024, the Texas Medicaid & Healthcare Partnership (TMHP) will update the Texas Medicaid Provider Procedures Manual (TMPPM), Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, section 5.2.2, “Genetic Tests,” to add language outlining coverage of biomarker testing required by Senate Bill (S.B.) 989 (88th Legislature, Regular Session, 2023).

Biomarker Testing

Biomarker testing that is supported by medical and scientific evidence as outlined in Chapter 1372 of Subtitle E, Title 8 of the Texas Insurance Code (TIC), as added by S.B. 989, is considered medically necessary when the use of the test informs a client’s outcome and a provider’s clinical decision. The test must meet one or more of the following criteria:

  • A United States Food and Drug Administration (FDA)-labeled indication for the test or an indicated test for a drug approved by the FDA
  • A national coverage determination made by the Centers for Medicare and Medicaid Services (CMS), or a local coverage determination by a Medicare administrative contractor
  • Nationally recognized clinical practice guidelines
  • Consensus statement recommendations for specific clinical circumstances when biomarker testing may optimize clinical care outcomes

Reimbursement

Procedure codes 81279, 81305, 81307, 81320, 81345, 81425, 81426, 81427, and 81443 will become a benefit for Texas Medicaid effective for dates of service on or after September 1, 2024. These procedure codes may be reimbursed to independent and privately owned laboratory providers for services rendered in the independent laboratory setting and will be limited to one service per lifetime to any provider.

Procedure codes 81425, 81426, 81427, and 81443 may be reimbursed with prior authorization. Refer to Genetic Services Biomarker Testing Expanded Carrier Screening Criteria for Prior Authorization and Genetic Services Biomarker Testing Whole Genome Sequencing Criteria for Prior Authorization for interim guidance for the expanded carrier screening (ECS) (procedure code 81443) and whole genome sequencing (WGS) (81425, 81426, 81427) benefits and related prior authorization criteria until future Texas Medicaid Provider Procedures Manual updates are finalized.

Exclusions

The following service will not be reimbursed by Texas Medicaid:

  • Biomarker testing not supported by medical and scientific evidence as outlined in Section 1372.003(a) (1-5) of TIC, or that does not show evidence of impact on client outcomes and a provider’s clinical decision

For more information, call the TMHP Contact Center at 800-925-9126.