Alabama
This data is meant to be used for educational purposes to inform providers, patients, insurers, and state Medicaid agencies what genetic services may or may not be written into each state’s Medicaid policy. The database is not meant to indicate or imply whether a certain program will cover a specific service, since many decisions are made on a case by case basis. If you have specific questions about whether a service is covered, you should reach out to your plan administrator. Please see this disclaimer below for more information.
Medicaid Coverage Information Published
State Contact Information
Stephanie Azar
Commissioner
Alabama Medicaid Agency
501 Dexter Avenue, PO Box 5624
Montgomery, AL 36103-5624
Phone: (334) 242-5600
Medicaid’s Central Office
501 Dexter Avenue
Montgomery, AL
36104
https://medicaiddirectors.org/wp-content/uploads/2023/06/Public_DirectorsList_June2023-1.pdf
General Genetic Testing Criteria
Genetic Testing Not Covered
Cell free fetal DNA testing is not covered for low-risk women or women with multiple gestations at this time.
Chromosomal studies (amniocentesis) on unborn children being considered for adoption are not covered.
State Specific Definition
Genetic Services for Children
Genetic Counseling Requirement
Alabama Genetic Counselor Licensure Application
https://agcb.alabama.gov/wp-content/uploads/2021/10/Application.pdf
Licensure Requirements:
Documentation of one of the following certifications:
- Genetic Counselor by the American Board of Genetic Counseling
- Genetic Counselor by the American Board of Medical Genetics
- Medical Geneticist by the American Board of Medical Genetics
State Board License Verification
Official transcript documenting a Master or Doctoral degree in genetic counseling from an approved program
Proof of U.S. Citizenship (copy of your U.S. passport, driver’s license, or birth certificate)
If you are not a U.S. citizen, you must submit documentation that will determine if you have a qualified alien status.
Metabolic Formula Coverage Legislation
Alabama
AC §22‐20‐3
AAC §40‐20‐10‐.01 et seq
Metabolic Formula Coverage & Criteria
Enteral Nutrition Equipment and Supplies:
Enteral nutrition equipment and supplies are covered for children under the age of 21 with an EPSDT Screening and Referral. Recipients age 21 and above (with noted limitations) qualify based on medical necessity and PA when the following criteria are met:
The recipient meets the following criteria for enteral nutrition:
- Recipient is < age 21 and record supports that > than 50 % of need is met by specialized nutrition; OR
- Recipient is > age 21 and record supports 100 % of need is met by specialized nutrition and provided by tube feedings AND must submit documentation from the prescriber to support that the recipient cannot tolerate bolus feeding and requires enteral nutrition by pump.
Enteral nutrition for adults 21 years of age and above is provided through bolus feeds using procedure code A4213
Total Parenteral Nutrition (TPN) Pump and Supplies:
All TPN supplies are provided to Medicaid recipients based on medical necessity when the following criteria are met:
- The recipient meets the criteria for total parenteral nutrition (TPN)
- Recipient < age 21 and record supports that > than 50% of need is met by specialized nutrition, or
- Recipient > age 21 and record supports 100% of need is met by specialized nutrition.
- The recipient cannot be sustained through oral feedings and must rely on enteral nutrition therapy which is administered by some form of intravenous therapy.
- Verification that the criteria have been met must accompany the PA request.
Prior Authorization Requirements
Required for Non-Invasive Prenatal Testing and Oncotype DXTM tests.
PA requests are required for most Enteral Nutrition Equipment and Supplies.
Prior Authorization Forms
Fee Schedule
BRCA Testing Coverage
No coverage
Requirements for BRCA
No
Cystic Fibrosis Screening
Hereditary Cancer Testing Coverage
No coverage
Lynch Syndrome Testing Coverage
No coverage
Microarray Testing
Newborn Screening
Panel Testing
Pharmacogenetic Testing
Prenatal Testing Offered
The Alabama Medicaid Agency will cover the following Non-Invasive Prenatal Test (NIPT) testing procedure codes with prior authorization:
- 81420 – Fetal chromosomal aneuploidy (e.g., trisomy 21, monosomy X) genomic sequence analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and 21
- 81507 – Fetal aneuploidy (trisomy 21,18, and 13) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy
Medicaid may cover these tests for women with singleton gestations considered at increased risk for fetal aneuploidy in whom cell free fetal DNA may be used as a primary screening option. The recipient must meet at least one of the criteria listed below:
- Maternal age 35 years or older at delivery; OR
- Fetal ultrasonographic findings indicating an increased risk of aneuploidy; OR
- History of a prior pregnancy with a trisomy; OR
- Parental balanced Robertsonian translocation with increased risk of fetal trisomy 13 or trisomy 21; OR
- Positive test result for aneuploidy, including first trimester, sequential, or integrated screen, or a quadruple screen.
- Providers may begin using the Medical PA Form for all requests for NIPT prior authorizations via the Forms menu of the Alabama Medicaid Interactive Web Portal. Supporting documentation should be submitted with the prior authorization form by uploading documents in PDF format or creating a fax barcode cover sheet from the Web Portal. Additional prior authorization supporting documentation must include the following:
- Evidence that pretest counseling included patient education inclusive of the following: Cell-free DNA testing is the most sensitive and specific screening test for the common fetal aneuploidies (Trisomy 13, 18, and 21). Cell-free DNA testing is not equivalent to diagnostic testing (Chorionic Villus sampling or Amniocentesis).
- A family history to determine if the patient should be offered other forms of screening or prenatal diagnosis for familial genetic disease.
Whole Exome Sequencing
Other Tests Covered
Effective for dates of service, July 1, 2013 and thereafter, Medicaid will
cover the Oncotype DXTM genetic profiling lab test if the patient meets
Medicaid’s prior authorization criteria. (PA). The PA must be received by
the fiscal agent within 30 days of the date of service.
Oncotype DXTM is a genetic profiling test developed to classify the risk of
recurrence among women treated for early stage breast cancer.
The use of the 21-gene reverse transcriptase-poleymerase chain
reaction ( RT-PCR) Assay (i.e., Oncotype DXTM) to determine recurrence
risk for deciding whether or not to undergo adjuvant chemotherapy meets
Alabama Medicaid’s medical criteria for coverage in women with early
stage breast cancer with ALL of the following characteristics:
- Newly diagnosed, primary, early stage breast cancer (stage I or stage
II) in a female without significant co-morbidities; - Unilateral, non-fixed tumor;
- Hormone receptor positive (ER-positive or PR-positive);
- HER2-negative;
- Tumor size 0.6-1cm with moderate/poor differentiation or unfavorable features OR tumor size > 1cm;
- Node negative; (lymph nodes with micrometastases [<2 mm in size]
are considered node negative for this policy statement) - Will be treated with adjuvant endocrine therapy, e.g., tamoxifen or
aromatase inhibitors; AND - When the test result will aid the patient in making the decision
regarding chemotherapy (i.e., when chemotherapy is considered a
therapeutic option); AND - When ordered within 6 months following breast cancer diagnosis.
- The 21-gene RT-PCR Assay Oncotype DXTM should only be ordered
on a tissue specimen obtained during surgical removal of the tumor
and after subsequent pathology examination of the tumor has been
completed and determined to meet the above criteria (i.e., the test
should not be ordered on a preliminary core biopsy). - The test should be ordered in the context of a physician-patient
discussion regarding risk preferences when the test result will aid in
making decisions regarding chemotherapy. The plan for discussion
must be documented in the patient’s clinical record. This discussion
must be documented in the patient’s clinical record and a copy of the
progress note (signed by the ordering physician) must accompany the
PA request (Form 342). - Prescription or order form for the test must be included
- The Oncotype DXTM test will be limited to one per lifetime, per
recipient. - Repeat tests will not be covered.
- The test will be limited to the following diagnoses: malignant
neoplasm of the female breast, carcinoma in situ of breast, and
personal history of malignant neoplasm, breast.
Other Information
Resources
https://www.al.com/news/2023/02/alabama-only-state-where-medicaid-wont-cover-some-breast-cancer-screening.html#:~:text=After%20North%20Carolina%20started%20covering,offer%20testing%20for%20Lynch%20Syndrome
https://medicaid.alabama.gov/content/Gated/7.6.1G_Provider_Manuals/7.6.1.3G_July2023/Jul23_20.pdf
https://medicaid.alabama.gov/content/Gated/7.6.1G_Provider_Manuals/7.6.1.3G_July2023/provman.pdf
Newborn Screening Reimbursement
On this Page
Disclaimer: The information contained in the database has been obtained from sources believed to be reliable but NCC has not attempted to validate or confirm the information. The database may be updated periodically. However, the accuracy and completeness of the information contained in the database cannot be, and is not, guaranteed. NCC makes no warranty of the accuracy, completeness or timeliness of this information, and shall not be liable for any decision made in reliance on this information. It is the user’s responsibility to verify this information by contacting the state Medicaid agency directly.
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