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
Director of Division of Health Care Services 240 Main St., Ste 202
Juneau AK 99801
General Genetic Testing Criteria
Alaska Medicaid covers medically necessary genetic testing when all of the following conditions are met:
- The recipient displays clinical features of a suspected genetic condition or is at direct risk of inheriting the genetic condition in question (e.g., a causative familial variant has been identified);
- Clinical studies published in peer-reviewed literature have established strong evidence that the result of the test will positively impact the clinical decision-making or clinical outcome for the member;
- The testing method is proven to be scientifically valid for the identification of a specific genetically-linked inheritable disease or clinically important molecular marker; and
- Documentation is provided from a physician with genetic expertise that supports the recommendation for testing based on a review of risk factors, clinical scenario, and family history.
Genetic Testing Not Covered
Alaska Medicaid does not cover:
- Services that do not appear on the Independent Laboratory Services Fee Schedule;
- Pharmacogenetics testing panels (e.g., GeneSight Psychotropic, Genecept Assay, SureGene Test, and Mental Health DNA Insight Panel) for any indication including psychotropic or pain medication prescribing;
- CPT 80300-80377;
- CPT 81228 and 81229 if the recipient has had CMA performed previously;
- CPT 81226 if the recipient is taking tetrabenazine;
- CPT 81227 (CYP2C9);
- CPT 81240 F2 or 81241 FV for
- Routine screening for pregnant women;
- Adults with idiopathic venous thromboembolism (VTE); or
- Adult family members of individuals with identified genetic mutations.
State Specific Definition
Genetic Services for Children
Genetic Counseling Requirement
Alaska Medicaid considers genetic counseling to be part of the evaluation and management service with no additional reimbursement for genetic counseling by itself.
Metabolic Formula Coverage Legislation
Metabolic Formula Coverage & Criteria
Prior Authorization Requirements
Claims for all genetic testing must be accompanied by a Genetic Testing Supporting Information form and a lab report. Failure to attach these documents will result in claim denial.
Prior Authorization Forms
BRCA Testing Coverage
Requirements for BRCA
Cystic Fibrosis Screening
Hereditary Cancer Testing Coverage
Lynch Syndrome Testing Coverage
Alaska Medicaid covers cytogenomic constitutional (genome-wide) microarray analysis (CMA) once in a recipient’s lifetime if the recipient has not had CMA performed previously. CPT 81228, interrogation of genomic regions for copy number variants (e.g., bacterial artificial chromosome [BAC] or oligo-based comparative genomic hybridization [CGH] microarray analysis) is covered if the recipient meets one or more of the following criteria:
- Has at least one major congenital anomaly or multiple congenital anomalies, other than those associated with an obvious, specific, and well-defined genetic syndrome;
- Has a developmental delay (DD) or intellectual disability (ID) and all of the following are met: there is no known etiology for the DD/ID (e.g., trauma, infection); the DD/ID is not suspected to be related to an obvious, specific, and well-defined genetic syndrome; the patient shows evidence of at least one major congenital anomaly.
- Has an autism spectrum disorder and has at least one major congenital anomaly Interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities (CPT 81229) is covered if the recipient meets the above criteria as well as on or more of the following: Consanguinity and recessive disease are suspected; Uniparental Disomy (UPD) is suspected; or Another mechanism is suspected that would not be detected by the oligo microarray.
Alaska Medicaid covers the test for CYP2C19 (CPT 81225) only for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) who are initiating or reinitiating Clopidogrel (Plavix). The test for CYP2D6 (CPT 81226) is covered only if one or more of the following criteria are met:
- Recipient is on doses of Pimozide of more than 4mg/day (adult) or 0.05mg/day (child)
- Recipient has Gaucher disease type 1 and is a candidate for and is considering treatment with eliglustat, and has received medication service authorization approval under the pharmacy benefit
- Recipient has failed at least two other antidepressants being initiated on antidepressant therapy with amitriptyline or nortriptyline.
Note: CYP2D6 will not be authorized for a patient prescribed amitriptyline or nortriptyline for neuropathic pain indications.
Prenatal Testing Offered
Whole Exome Sequencing
Other Tests Covered
Alaska Medicaid covers spinal muscular atrophy (SMA) carrier screening (CPT 81329) for once per lifetime for recipients with a positive pregnancy test and one of the following conditions:
- Previous carrier status in at least one parent; and
- Family history of SMA in first or second degree relative of high risk partner (maternal or paternal).
Alaska Medicaid covers breast cancer gene expression profiling once in a recipient’s lifetime if the recipient has not been tested previously, regardless of payer.
- Coagulation Factors II and V
- “Alaska Medicaid covers coagulation factor II (CPT 81240 F2) and V (CPT 81241 FV) gene analysis for recipients under 21 years of age experiencing spontaneous thrombosis, non-catheter related venous thrombosis, or stroke. “
- Genetics Pediatric Clinic – “The Providence Genetics Clinic will be staffed by a coordinator, genetic counselors and contracted out-of-state Geneticists. Clinics will be held every other month and the genetics team will continue to travel to Fairbanks and Juneau for outreach clinics.”
- AK Provider Billing Manual, Independent Laboratory, Genetic Testing http://manuals.medicaidalaska.com/independent_lab/independent_lab.htm
- AK Provicer Billing Manual, Durable Medical Equipment, Medicaid Covered Services http://manuals.medicaidalaska.com/dme/dme.htm
- AK Provider Billing Manual, Physician, Medicaid Covered Services http://manuals.medicaidalaska.com/physician/physician.htm Alaska Coagulation Factors II and V http://dhss.alaska.gov/dph/wcfh/Pages/geneticspecialty/default.aspx
Newborn Screening Reimbursement
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.