Genetic Testing Prior Authorization Requirement Reminder

Date: March 26, 2021 Attention: All Providers Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event. Call to action: Texas Children’s Health Plan (TCHP) would like to remind network providers that all genetic testing requires an approved prior authorization before the laboratory tests can be completed. Quest Diagnostics is the exclusive reference laboratory provider for TCHP.  If a laboratory test is not available at Quest Diagnostics, an out-of-network prior authorization must be obtained in order for the service to be performed at a different laboratory provider. Quest Diagnostics is the laboratory provider for prenatal screening and Noninvasive Prenatal Testing (NIPT). The CPT Codes are as follows:

• Cystic Fibrosis (81220)
• Spinal Muscular Atrophy (SMA) Carrier Screening (81329)
• NIPT (81420) and related codes

For prenatal screening, a request for retroactive authorization must be submitted no later than seven    calendar days beginning the day after the lab draw is performed. TCHP will apply clinical criteria in the current Texas Medicaid Provider Manual (TMPPM), at the time of the request, when applicable for the following:

• BRCA gene mutation analysis
• Genetic Testing for colorectal cancer
• Cytogenetic testing
• Pharmacogenetic Testing

  How this impacts providers: Genetic testing codes that require an authorization effective March 1, 2021:

• 81202 APC (adenomatous polyposis coli) (eg, familial adenomatosis
• 81203 APC (adenomatous polyposis coli) (eg, familial adenomatosis
• 81212 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repa
• 81224 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; intron 8 poly-T analysis
• 81233 BTK (Bruton’s tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants
• 81237 EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large B-cell lymphoma) gene analysis, common variant(s)
• 81238 F9 (coagulation factor IX) (eg, hemophilia B), full gene sequence
• 81247 G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; common variant(s)
• 81248 G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; known familial variant(s)
• 81249 G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full gene sequence
• 81275 KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carci)
• 81301 Microsatellite instability analysis (eg, hereditary non-poly
• 81318 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (
• 81334 RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analysis (eg, exons 3-8)
• 81364 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); full gene sequence
• 81303 MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; known familial variant
• 81304 MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; duplication/deletion variants
• 81322 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant
• 81329 SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing), includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed
• 81336 SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; full gene sequence
• 81337 SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familial sequence variant(s)
• 81341 TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (eg, Southern blot)

References: TCHPGenetic Testing Guidelines Provider alert: Updates to Prior Authorization Requirements for Genetic Testing, Wheelchair accessory, and Personal Care ServicesTMPPM Radiology and Laboratory Services Handbook   Next steps for providers: Providers must adhere to the TCHP prior authorization guidelines for genetic testing and should secure an approved authorization before the laboratory tests are performed. The prior authorization form is available here.   If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.For access to all provider alerts,log into: www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.