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Genetic Testing Benefit Criteria to Be Added to the TMPPM Radiology and Laboratory Services Handbook

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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 October 1, 2025, the Texas Medicaid & Healthcare Partnership (TMHP) will update the Texas Medicaid Provider Procedures Manual (TMPPM) Radiology and Laboratory Services Handbook as follows:

  • Genetic testing benefit criteria will be added.
  • Prior authorization criteria will be added for expanded carrier screening (ECS) and whole genome sequencing (WGS).
  • The following sections will be updated after they are moved from the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook to the Radiology and Laboratory Services Handbook:
    • 5.2.2, “Genetic Tests”
    • 5.2.3, “Biomarker Testing”
    • 5.2.4, “Laboratory Practices”

Genetic Testing

Genetic testing is the study of heredity by using various techniques, including analysis of human DNA, RNA, or protein.

Genetic testing may be a benefit of Texas Medicaid when it meets medical necessity criteria. To be considered medically necessary, all the following conditions are required:

  • The client displays clinical features or is at direct risk of inheriting the mutation in question (presymptomatic).
  • The result of the test will directly affect the treatment that the client receives.
  • A definitive diagnosis remains uncertain after a review of the client’s medical history, a physical examination, pedigree analysis, genetic counseling, and completion of conventional diagnostic studies.
  • The client exhibits disease-specific criteria.

The definition of medical necessity for genetic testing is also guided by Chapter 1372 of Subtitle E, Title 8, of the Texas Insurance Code. This statute requires that biomarker testing, including relevant genetic tests, be supported by medical and scientific evidence, as described by 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
  • Local and national coverage determinations made by a Medicare administrative contractor and the Centers for Medicare & Medicaid Services (CMS)
  • Nationally recognized clinical practice guidelines
  • Consensus statement recommendations for specific clinical circumstances when biomarker testing may optimize clinical care outcomes

Genetic testing includes the following tests:

  • Single-analyte
  • Multiplex panel
  • WGS

Note: For specific genetic testing criteria, refer to the TMPPM Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook, the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, and the Radiology and Laboratory Services Handbook.

Prior Authorization

Prior authorization is not required for genetic testing unless individual specific genetic testing criteria specify it.

Prior authorization is required for ECS and WGS. Providers may refer to the following published articles for prior authorization criteria:

The ordering provider that is rendering direct care must sign, date, and submit a Special Medical Prior Authorization (SMPA) Request Form to request prior authorization for genetic testing.

TMHP will not process prior authorization requests from laboratories.

Note: The ordering provider must share the prior authorization number with the laboratory that will submit the claim.

Documentation Requirements

To meet the requirements for medical necessity and avoid unnecessary claim denials, the physician must submit correct and complete information. This includes the following:

  • An explanation of the medical necessity of the requested equipment or supplies
  • Documentation that supports the medical necessity of the procedure code that is submitted for reimbursement
  • Up-to-date records in support of medical necessity in the client’s medical record

Reimbursement

The following procedure codes may be reimbursed for genetic testing services:

Procedure Codes
81105811068110781109811108111181112
81120811218116181162811638116481165
81166811678117081177811788117981180
81181811848118581186812008120181202
81203812058120681207812088120981210
81212812158121681217812188121981220
81221812228122381224812258122681227
81229812338123581237812388124081241
81242812438124481245812468124781248
81249812508125181252812538125481255
81256812578125881259812608126181262
81263812648126581266812678126881269
81270812728127381275812768127881279
81287812888129081291812928129381294
81295812968129781298812998130081301
81302813038130481305813078131081313
81314813158131681317813188131981320
81321813228132381324813258132681327
81329813308133181332813348133681337
81340813418134281345813498135081351
81352813538135581361813628136381364
81370813718137281373813748137581376
81377813788137981380813818138281383
81400814018140281403814048140581406
81407814088141081411814208142581426
81427814438144981450814518145581456
81457814588145981462814638146481507
8151381514815198152081528S3800S3840
S3841S3842S3846    

The following procedure codes will no longer be reimbursed when they are submitted with the provider types and places of service listed below:

Procedure Codes
81200812058120981220812218122281223
81224812428124381244812508125181255
81256812578126081265812668126781268
81270812878128881290813028130381304
81310813308133181332813508135581370
8137181372813758137881379S3800 

Impacted Provider Types and Settings:

  • Office Setting:
    • Physician assistant
    • Nurse practitioner
    • Clinical nurse specialist
    • Physician
    • Certified nurse midwife
  • Outpatient Hospital Setting:
    • Hospital providers
    • Rural emergency hospital providers

Providers may also refer to the Texas Medicaid fee schedule for a list of procedure codes that may qualify for reimbursement.

Exclusions

The following services are not covered benefits of Texas Medicaid:

  • Genetic testing that is not supported by medical and scientific evidence as outlined in Chapter 1372 of Subtitle E, Title 8, of the Texas Insurance Code or that does not show evidence of clinical utility.

    Clinical utility is defined under Chapter 1372 of Subtitle E, Title 8, of the Texas Insurance Code as a test result that provides information used in the formation of treatment or monitoring strategies that inform a client’s outcome and impact the clinical decision. The most appropriate test may include both information that is actionable and some information that cannot be immediately used in the formation of a clinical decision. 
     
  • Genetic testing that is not primarily intended to treat the acute or chronic issue for which the test is being ordered.

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