Georgia

Lynnette Rhodes
Georgia Department of Community Health, Medicaid
(404) 656-4507

Molecular Diagnostic Testing
Procedure codes in the range 81500-81512, 87481 and 87798 when greater than one unit of service is required and when medical necessity supports the procedures that normally receive a National Correct Coding Initiative exception will be considered for payment.

The list below represents common procedures and settings in which services are non-covered. This list is not meant to be exhaustive but is indicative of non- covered services:

1. Procedures completed in laboratories operated as a part of a physician’s private office (described in the Policies and Procedures for Physician Services);
2. Procedures completed in laboratories providing services to hospital patients, operating on the premises of a hospital that meets the definition of an emergency hospital (described in the Policies and Procedures for Hospital Services);
3. Procedures referred to another testing facility;
4. Experimental services or procedures or those not recognized by the United States Public Health Service as universally accepted procedures;
5. Procedures deleted from previous and current editions of the CPT and those shown as “Unlisted Procedure” which end in “99”;
6. Professional interpretation for procedures normally interpreted by an attending practitioner; g) Services and/or procedures performed without regard to the policies contained in this manual;
7. Services provided free-of-charge to Medicaid members by state or public laboratories;
8. The collection and handling of specimens sent to an independent laboratory for further distribution to another testing facility;
9. Laboratory test procedures included in the dialysis facility’s composite rate;
10. Specimen collection and or handling fee (Venipuncture or Catherized Urine);
11. Services for which the performing provider does not have appropriate CLIA certification; or
12. Reimbursement for more than twenty-five multiple drug screens per member per fiscal year.

A request for prior approval must be submitted at least one week prior to the planned laboratory test. Laboratory tests performed prior to receipt of an approved request may risk denial of reimbursement. Failure to obtain required prior authorization shall result in denial of reimbursement.

Coverage is available.

Genetic Testing: CareSource will review for medical necessity and approve genetic testing based on all of the criteria below found under ONE of the following situations:

• Published MCG policy with endorsed inclusion criteria meeting all of the following:
  • Documentation of an assessment based on the relevant MCG Guideline AND
  • The quality, safety, statistical validity, and clinical validity is scientifically supported in medical literature as endorsed by inclusion criteria of the relevant MCG Guideline AND
  • Genetic counseling has been performed, as indicated by documentation supporting ALL of the following items listed below:
    • Counseling is provided by a healthcare professional (as defined below) with education and training in genetic issues relevant to the genetic tests under consideration, AND
    • Counselor is free of commercial bias and discloses all (potential and real) financial and intellectual conflicts of interest, AND
    • Process involves individual or family and is comprised of ALL of the following:
      • Calculation and communication of genetic risks after obtaining 3-generation family history AND
      • Discussion of natural history of condition in question, including role of heredity AND
      • Discussion of possible impacts of testing (e.g., psychological, social, limitations of nondiscrimination statutes) AND
      • Discussion of possible test outcomes (i.e., positive, negative, variant of uncertain significance) AND
      • Explanation of potential benefits, risks, and limitations of testing AND
      • Explanation of purpose of evaluation (e.g., to confirm, diagnose, or exclude genetic condition) AND
      • Identification of medical management issues, including available prevention, surveillance, and treatment options and their implications
        AND
      • Written documentation that the patient has provided informed consent to the testing as evidenced by a statement detailing how the test results will affect the patient’s medical management

Source: https://www.caresource.com/documents/medicaid-ga-policy-medical-mm-0735-20191115/

Yes; same requirements as for BRCA.

Yes; same requirements as for BRCA.

Georgia Breast Cancer Genomics Project

• Provider Manual, DURABLE MEDICAL EQUIPMENT SERVICES, Policy 1109 Nutritional Therapy or Supplementation Services
  • https://www.mmis.georgia.gov/portal/PubAccessProviderInformation/ProviderManuals/tabid/54/Default.aspx
• Georgia Breast Cancer Genomics Project https://dph.georgia.gov/BCCP
• Newborn Screening: https://dph.georgia.gov/NBS/nbs-policies-and-procedures
• Medicaid Information
  • https://medicaid.georgia.gov/
• Independent Lab Manual
  • https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Provider%20Manuals/tabId/39/Default.aspx