Kansas

Yes

Sarah Fertig, Medicaid Director and Interim Division Director
(785)-296-3512

Cytogenetic (chromosome) studies are covered for pregnant women (when medically necessary) and KBH-EPSDT beneficiaries only. A medical necessity form must accompany the claim when billing for a cytogenetic study for a pregnant woman over 21 years of age.

Genetic testing is covered only when:

1. There are signs and/or symptoms of an inherited disease in the affected individual.
2. There has been a physical examination, pretest counseling, and other diagnostic studies.
3. The determination of the diagnosis in the absence of such testing remains uncertain and would impact the care and management of the individual on whom the testing is performed.

https://www.sunflowerhealthplan.com/providers/preauth-check/medicaid-pre-auth.html

https://portal.kmap-state-ks.us/PublicPage/ProviderPricing/ProviderInteractiveTools

Coverage is available.

Genetic testing is covered only when:

1. There are signs and/or symptoms of an inherited disease in the affected individual.
2. There has been a physical examination, pretest counseling, and other diagnostic studies.
3. The determination of the diagnosis in the absence of such testing remains uncertain and would impact the care and management of the individual on whom the testing is performed.

KMAP will consider the following for coverage:
The use of the 21-gene reverse transcriptase-polymerase chain reaction (RT-PCR) assay that is not considered experimental or investigational (such as Oncotype DX®, EndoPredict®, Breast Cancer IndexSM, and Prosigna®) to determine recurrence risk for deciding whether to undergo adjuvant chemotherapy may be considered medically necessary in individuals with primary, invasive breast cancer meeting ALL of the following characteristics:

1. Unilateral tumor;
2. Hormonereceptor-positive;
3. Human epidermal growth factor receptor 2 (HER2) –negative;
4. Tumor size 0.6 to 1 cm with moderate/poor differentiation or unfavorable features OR tumor size larger than 1 cm;
5. Node negative (lymph nodes with micrometastases [less than 2 mm in size] are considered node negative for this policy statement);
6. Will be treated with adjuvant endocrine therapy;
7. When the test result will aid the patient in making the decision regarding chemotherapy (e.g. when chemotherapy is a therapeutic option);
8. When ordered within six months following diagnosis, since the value of the test for making decisions regarding delayed chemotherapy is unknown.

Coverage is available.

Cytogenomic Constitutional (Genome-Wide) Microarray Analysis is considered medically necessary for ONE OR MORE OF the following medical indications:

• Multiple congenital anomalies, other than those associated with an obvious, specific, and well-defined genetic syndrome. After history, physical examination, pedigree analysis, genetic counseling, and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain.
• Developmental delay (DD) or Intellectual Disability (ID) when all of the following are met:
  • There is no known etiology for the DD/ID (e.g., trauma or infection)
  • The DD/ID is not suspected to be related to an obvious, specific, and well-defined genetic syndrome. After history, physical examination, pedigree analysis, genetic counseling, and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain.
• The member shows evidence of at least one major OR two or moreminor congenital anomalies as defined above.

DNA-based noninvasive prenatal tests of fetal aneuploidy are proven and medically necessary as screening tools for trisomy 21 (Down syndrome), trisomy 18 (Edwards syndrome) or trisomy 13 (Patau syndrome) in any one of the following circumstances:

1. Maternal age of 35 years or older at delivery;
2. Fetal ultrasound findings indicating an increased risk of aneuploidy;
3. History of prior pregnancy with trisomy;
4. Positive first or second trimester screening test results for aneuploidy;
5. Parental balanced Robertsonian translocation with an increased risk of fetal trisomy 13 and 21.

“The Kansas Special Health Care Needs (SHCN) Program promotes the functional skills of persons, who have or are at risk for a disability or chronic disease. The program is responsible for the planning, development, and promotion of the parameters and quality of specialty health care in Kansas in accordance with state and federal funding and direction. SHCN provides specialized medical services to infants, children and youth up to age 21 who have eligible medical conditions. Additionally, the program provides services to persons of all ages with metabolic or genetic conditions screened through the Newborn Screening.”
http://www.kdheks.gov/shcn/index.htm

• Fee-for-Service Provider Manual (2020)
  • https://www.kmap-state-ks.us/Documents/Content/Provider%20Manuals/Professional_20182_20181.pdf
• DMS Fee-for-Service Provider Manua
  • https://www.kmap-state-ks.us/Documents/Content/Provider%20Manuals/DME_21009_20255.pdf Additional Newborn Screening: http://www.kdheks.gov/shcn/index.htm