Georgia
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
Frank W. Berry, Commissioner of Georgia Department of Community Health
Georgia Medicaid:
Primary: (404) 657-5468
Toll Free: (877) 423-4746
Online Forum: https://dch.georgia.gov/contact-dch
General Genetic Testing Criteria
Genetic Testing Not Covered
State Specific Definition
Genetic Services for Children
Genetic Counseling Requirement
On May 7, 2019, Georgia became the 28th state to enact a bill providing for licensure of genetic counselors. As of January 1, 2020, all genetic counselors practicing in the state of GA will be required to hold a license. Licensure provides title protection such that consumers can be assured that when they make an appointment with a genetic counselor in the state of GA, that clinician has been suitably trained in genetics. Only individuals who qualify for a license are eligible to use the title “licensed genetic counselor,” “genetic counselor,” or other insignia/designation that would imply that the individual is licensed as a genetic counselor. Consumers are encouraged to look for this designation when making an appointment for genetic counseling.
Metabolic Formula Coverage Legislation
GC §31‐12‐6
Metabolic Formula Coverage & Criteria
Oral nutrition will be considered for coverage when it is ordered by a physician and there is sufficient documentation to provide evidence that the member has an inborn metabolic or genetic error or disorder (i.e., PKU disease) or is unable to tolerate common food products, including liquid food in a can, in sufficient amounts to prevent mental retardation or death. Suppliers of nutritional products should submit a request for prior authorization for all orders received for nutritional products so that a determination can be made on a case-by-case basis where applicable.
Medical foods require prior authorization and will be considered for coverage if the member meets all the following criteria are met:
- The member has an inborn error of metabolism that interferes with the ability to metabolize specific nutrients, including, but not limited to:
- Phenylketonuria (PKU); or
- Homocystinuria; or
- Methylmalonic acidemia
- The treating physician has ordered the most appropriate medical food based on the member’s condition, that is:
- A medical food requiring a prescription; and
- A medical food that is labeled and used for the dietary management of a specific disease or disorder that presents specific nutritional requirements to avoid the development of physical or mental disabilities
- The medical food is the primary source of nutrition (constitutes more than fifty (50) percent of the nutritional intake).
Prior Authorization Requirements
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. The documentation that must be submitted to substantiate the request for a genetic testing PA should include:
- Physician/ Nurse Practitioner/ Physician Assistant Order
- Clinical Notes from the Medical Chart belonging to the provider signing the order which should include appropriate history, physical exam, etc.
- Additional Supporting Clinical Documents which may include related testing and genetic counseling.
Prior Authorization Forms
Fee Schedule
BRCA Testing Coverage
Coverage is available, but criteria is unknown.
Requirements for BRCA
Cystic Fibrosis Screening
Coverage is available, but criteria is unknown.
Hereditary Cancer Testing Coverage
Lynch Syndrome Testing Coverage
Coverage is available, but criteria is unknown.
Microarray Testing
Newborn Screening
Georgia Medicaid covers newborn screening.
Panel Testing
The following CPT codes for panel testing requires prior authorization:
- 81445 Targeted Genomic Sequence Analysis Panel of DNA Or Combined DNA And
RNA 5-50 Associated with Solid Organ Neoplasm - 81449 Targeted Genomic Sequence Analysis Panel of RNA of 5-50 Genes Associated
with Solid Organ Neoplasm - 81451 Targeted Genomic Sequence Analysis Panel of RNA of 5-50 Genes Associated
with Blood and Lymphatic System Disorders - 81455 Targeted Genomic Sequence Analysis Panel of DNA or Combine DNA and
RNA of 51 of Greater Genes Associated with Blood and Lymphatic System
Disorders - 81456 Targeted Genomic Sequence Analysis Panel of RNA of 51 or Greater Genes
Associated with Blood and Lymphatic System Disorders
Pharmacogenetic Testing
Coverage is available, but criteria is unknown.
Prenatal Testing Offered
Coverage is available, but criteria is unknown.
Whole Exome Sequencing
CPT code 81415, Test for Detecting Exome, Sequence Analysis requires prior authorization.
Other Tests Covered
Perinatal genetic counseling will be covered when provided by an employee/contracted agent of a hospital. These services must be performed by a master’s prepared certified genetic counselor in conjunction with a physician who is board certified in Genetic medicine. Genetic counseling services provided are to be non-directive, outcome planning related and used to factually inform both the physician and parents of possible genetic
impacts and anomalies. Services will be limited to three (3) counseling sessions within an eleven-month period for an eligible Medicaid member. This is to include one (1) initial screening interview and up to two (2) follow-up sessions for discussion and clarification of issues.
The following CPPT codes require prior authorization:
- 81401 Molecular Pathology Procedure Level 2
- 81403 Molecular Pathology Procedure Level 4
- 81404 Molecular Pathology Procedure Level 5
- 81405 Molecular Pathology Procedure Level 6
- 81406 Molecular Pathology Procedure Level 7
- 81408 Molecular Pathology Procedure Level 9
Other Information
Resources
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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