Minnesota
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
Julie Marquardt
Acting Assistant Commissioner for Health and
Medicaid Director
Minnesota Department of Human Services
540 Cedar Street, PO Box 64983
St. Paul, MN 55167-0983
Phone: (651) 431-4280
https://medicaiddirectors.org/wp-content/uploads/2023/06/Public_DirectorsList_June2023-1.pdf
General Genetic Testing Criteria
MHCP covers genetic testing when medically necessary. Genetic testing is considered medically necessary when all of the following conditions are met and documented in the medical record:
- The member displays clinical features or is at direct risk of inheriting the genetic condition in question (pre-symptomatic)
- The result of the test will have a clinically significant impact on the treatment being delivered for a disease or syndrome
- The testing method is considered scientifically valid for the identification of a specific genetically linked inheritable disease
- Appropriate genetic counseling occurs before and after testing. Counseling documentation supports the intent to change therapy based on the results of the testing
Genetic Testing Not Covered
Genetic testing is not covered when performed in the absence of symptoms or high-risk factors for an inheritable disease or when knowledge of genetic status will not affect treatment decisions. Tests for conditions that are treated symptomatically are not appropriate since the treatment would not change due to the test results.
Pharmacogenetic panel tests for therapy selection, such as panel tests for psychotropics, analgesics or ADHD stimulant medications, are not covered.
MHCP does not cover cytogenetic testing for:
- Legal, paternity or informational purposes
- Family members who are not MHCP members
- Fetus testing
State Specific Definition
Genetic Services for Children
Genetic Counseling Requirement
Genetic counselors are required to be licensed. For a full list of licensure requirements see below:
https://mn.gov/boards/assets/GC%20application%20packet%202023_tcm21-444094.pdf
Appropriate genetic counseling must occur before and after testing.
Genetic counseling is covered by Medicaid.
Genetic counselors or geneticists are physician extenders and may conduct a consultation to render an opinion or advice. The following conditions apply:
- The genetic counselor or geneticist may only initiate diagnostic or therapeutic services at the request of the attending physician.
- Follow-up consultations may be performed if it is medically necessary to reevaluate a member for whom an opinion previously has been rendered.
- Consultations provided by a genetic counselor may be billed using 96040 or S0265.
Metabolic Formula Coverage Legislation
Minnesota Administrative Rules 9505.0325 “NUTRITIONAL PRODUCTS”
Metabolic Formula Coverage & Criteria
Enteral nutrition products may be medically necessary for medical conditions related to malabsorption or malnutrition. The condition must have resulted in weight loss or difficulty maintaining a healthy weight. Medical necessity for enteral nutrition must demonstrate that if the member were left untreated by oral enteral nutrition they would risk detrimental effects to their health.
Examples of a condition CAN include:
- Mechanical inability to chew or swallow solid or pureed or blenderized foods
- Malabsorption due to disease or infection
- An oral aversion which significantly limits the ability to get adequate nutrients
- Weaning from TPN or feeding tube
- Inborn errors of metabolism
An enteral nutritional product is a covered service and does not require prior authorization if it is necessary to treat a condition listed in items A to D:
- phenylketonuria;
- hyperlysinemia;
- maple syrup urine disease; or
- a combined allergy to human milk, cow milk, and soy formula.
Prior Authorization Requirements
Some genetic tests require PA. BRCA genetic mutation testing requires PA.
Prior Authorization Forms
Fee Schedule
BRCA Testing Coverage
BRCA genetic mutation testing for breast and ovarian cancer in women requires Prior Authorization. Prior Authorization will be approved in cases where the results will impact the care of the member.
Requirements for BRCA
For BRCA genetic mutation testing, the member must meet criteria in either 1 or 2:
Member is identified as high-risk for a BRCA mutation and is one of the following:
- Is of Ashkenazi Jewish descent with breast or ovarian cancer. This includes any first-degree relative (or two second-degree relatives on the same side of the family)*. This also includes any other ethnicity or population for which “founder” mutations in the BRCA genes have been identified.
- Is of an ethnicity that is not Ashkenazi Jewish and has one or more of the following:
- Two first-degree relatives with breast cancer, one of whom was diagnosed at age 50 or younger
- A combination of three or more first or second-degree relatives with breast cancer regardless of age of diagnosis
- Any combination of breast and ovarian cancer among any combination of first and second-degree relatives
- A first-degree relative with bilateral breast cancer
- A combination of two or more first or second-degree relatives with ovarian cancer, regardless of age of diagnosis
- A first or second-degree relative with both breast and ovarian cancer at any age
- History of breast cancer in a male relative
Member has personal history of breast or ovarian cancer and wishes to inform future reproductive decision-making.
*A first-degree relative is a person’s parent, sibling, or child. A second-degree relative is a person’s aunt, uncle, grandparent, grandchild, niece, nephew or half-sibling.
Cystic Fibrosis Screening
Yes, if general genetic criteria is met.
Hereditary Cancer Testing Coverage
Yes, if general genetic criteria is met.
Lynch Syndrome Testing Coverage
Yes, if general genetic criteria is met.
Microarray Testing
Coverage is available.
Newborn Screening
MHCP will reimburse for the MDH newborn screening for metabolic disorder card in the diagnosis-related group (DRG) or facility fee only when provided in an inpatient or birthing center setting. Do not bill separately from facility fee.
MHCP will cover the cost of the newborn screening metabolic disorder card when screening cannot be completed at the inpatient hospital or birthing center setting with HCPCS code S3620, if MDH requests a repeat newborn screening card, bill S3620 and modifier 76 or 77.
Panel Testing
Coverage is available.
Pharmacogenetic Testing
Pharmacogenetic testing is covered when all the following conditions are met:
- Testing is required by the drug label
- The test will change the treatment course
- A drug trial is considered impractical due to safety or other factors before genetic testing
Prenatal Testing Offered
Coverage is available.
Whole Exome Sequencing
Rapid whole genome sequencing is a genetic test medically necessary when all of the following criteria are met:
- Critically ill infant or child in the intensive care unit (ICU) with no unifying diagnosis.
- Clinical circumstances present the need for rapid testing in time-sensitive cases as a last resort to guide clinical decision making in treatment or management of patient’s genetic condition.
- Test must be ordered by the infant’s treating physician and, before ordering testing, infant must be evaluated by a medical geneticist or other physician subspecialist with expertise in the conditions or genetic disorder for which the testing is being considered
AND - One of the following is met:
- Critically ill infant or child with a history of multiple hospitalizations or readmissions within 30 days of discharge for an unexplained condition which no diagnosis has been reached despite extensive workup and previous testing in the identification of rare genetic disease variant; or
- Clinical presentation does not fit a well-defined gene analysis test that is available or previous extensive workup and testing has failed to receive a diagnosis.
Other Tests Covered
Genetic testing for breast cancer aims to help breast cancer patients and their physicians determine whether adjuvant chemotherapy would be beneficial. Genetic testing is considered medically necessary for members with all of the following breast cancer characteristics:
- Stage I or II breast cancer
- Breast tumor is estrogen-receptor positive
- Breast tumor is HER2-receptor negative
- Tumor size 0.6-1 cm with moderate or poor differentiation or unfavorable features, or tumor size greater than 1 cm
- Negative lymph nodes (nodes with micrometastases greater than 2 mm in size)
- Test result will be used to guide decision making about adjuvant chemotherapy
Other Information
Exome and genome testing requirements will be reviewed on a case-by-case basis. Claims must include an attachment that explains the medical necessity for the test and indicates how the results of the test will influence treatment. Claims will pend until each case is reviewed for the medical necessity of the test and what the results of the test will have on treatment.
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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