Kansas

Updated on February 15, 2023

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

Yes

State Contact Information

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

General Genetic Testing Criteria

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.

Genetic Testing Not Covered

State Specific Definition

Genetic Services for Children

Genetic Counseling Requirement

Metabolic Formula Coverage Legislation

Metabolic Formula Coverage & Criteria

Prior Authorization Requirements

Prior Authorization Forms

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

Fee Schedule

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

BRCA Testing Coverage

Coverage is available.

Requirements for BRCA

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.

Cystic Fibrosis Screening

Hereditary Cancer Testing Coverage

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.

Lynch Syndrome Testing Coverage

Coverage is available.

Microarray Testing

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.

Newborn Screening

<p>Coverage is available.</p>

Panel Testing

Pharmacogenetic Testing

Prenatal Testing Offered

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.

Whole Exome Sequencing

Other Tests Covered

Other Information

“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

Resources

  • 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
Newborn Screening Reimbursement

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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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