Montana

Yes

Adam Meier, Director of Health and Human Services
(406) 444-5623

1. Pre- and post-test genetic counseling must be provided;
2. The requested test must be performed by a CLIA-certified laboratory;
3. Genetic testing is recommended in place of, to confirm or to rule out, a clinical diagnosis;
4. The requested test is not considered experimental or investigational;
5. The requested laboratory test is to provide clinical benefit (the course of treatment may change) to the patient;
6. Current signs or symptoms, or a family history suggest a genetic condition;
7. Current medical records (applicant must have been seen within the last six months) and physician notes verify the confirmed or suspected medical condition for which testing is being planned.

Genetic testing for Children’s Mental Health is covered. Youth must meet the SED criteria as described in this manual and additional criteria below:

1. Youth displays clinical feature or is at direct risk of inheriting a gene that testing is necessary to improve clinical outcomes of neuropsychiatric medication.
2. Documented previous medication failures and intent to alter medication course consistent with test results. Youth must have failed or currently be failing on at least one neuropsychiatric medication.
3. Results of test will directly impact treatment being delivered to the patient.
4. Documentation of risk and clinical need must include a comprehensive history, physical examination and completion of conventional diagnostic studies.

It is mandatory that a client who is at risk for BRCA1, BRCA2, or BRCA large rearrangement genetic mutation receive genetic counseling before and after BRCA gene mutation testing.

https://medicaidprovider.mt.gov/docs/forms/dmemedicaidpriorauth102014f.pdf

https://medicaidprovider.mt.gov/docs/feeschedules/2022FS/January2022/January2022LabServicesFeeScheduleREVISED04272022.pdf

• Personal history of any of the following:
• Breast cancer diagnosis at or before age 45.
• Breast cancer diagnosis at or before age 50 with any of the following:
• An additional breast cancer primary;
  • 1 or more close blood relative with breast cancer at any age;
  • 1 or more close blood relative with pancreatic cancer; or
  • 1 or more close blood relative with prostate cancer with a Gleason score ≥7.
• 4. Breast cancer diagnosis at or before age 60 with:
  • Triple negative breast cancer.
• 5. Breast cancer diagnosis at any age with any of the following:
  • 1 or more close relatives with breast cancer diagnosed before age 50;
  • 2 or more close blood relatives with breast cancer diagnosis at any age;
  • 1 or more close blood relative with ovarian cancer diagnosis;
  • 2 or more close blood relatives with pancreatic cancer diagnosis or prostate cancer diagnosis with a Gleason score ≥7;
  • 1 or more close blood relative diagnosed with male breast cancer.
• 6. Male breast cancer diagnosis at any age.
• 7. Ovarian cancer diagnosis at any age.
• 8. Fallopian tube cancer diagnosis at any age.
• 9. Primary peritoneal cancer diagnosis at any age.
• 10. Prostate cancer diagnosis with a Gleason score 7 at any age with any of the following:
  • 1 or more close blood relative with ovarian cancer at any age;
  • 1 or more close blood relative with breast cancer before age 50;
  • 2 or more close blood relatives with breast,pancreatic, or prostate cancer (Gleason score ≥7) at any age.
• 11. Pancreatic cancer diagnosis at any age with any of the following:
  • aAshkenazi Jewish ancestry;
  • 1 or more close blood relative with ovarian cancer at any age;
  • 1 or more close blood relative with breast cancer before age SO;
  • 2 or more close blood relatives with breast,pancreatic,or prostate cancer (Gleason score ≥7) at any age.
• Family history of any of the following:
  • First or second degree blood relative who meet any of the above criteria.
  • Third degree blood relative who has breast cancer and/or ovarian cancer and who has 2 or more close blood relatives with breast cancer (at least one with breast cancer before age SO) and/or ovarian cancer.
  • 1 or more family member with a known potentially harmful mutation In the BRCAl or BRCA2 gene.

Coverage is available.

Coverage is available.

1. Amino acid metabolism disorders, including Phenylketonuria (PKU), Maple Syrup Urine Disease (MSUD), Homocystinuria (HCY), Citrullinemia/ Arginosuccinic Acidemia (CIT/ASA) and Tyrosinemia Type I (TYR1).
2. Organic acidemia disorders, including 3-hydroxy-3-methylglutaryl-CoA lyase deficiency (HMG), 3-Methylcrotonyl-CoA carboxylase deficiency (3MCC), β-ketothiolase deficiency (BKT), Glutaric acidemia type I (GA1), Isovaleric acidemia (IVA), Methylmalonic acidemia (MUT and CblA,B), Multiple carboxylase deficiency (MCD), Propionic acidemia (PROP).
3. Fatty acid oxidation disorders, including Carnitine uptake defect (CUD), Medium-chain acyl-CoA dehydrogenase deficiency (MCAD), Long-chain L-3-hydroxyacyl-CoA dehydrogenase deficiency (LCHAD), Very long-chain acyl-CoA dehydrogenase deficiency (VLCAD), and Trifunctional protein deficiency (TFP). Congenital hypothyroidism (CH),
4. Congenital adrenal hyperplasia (CAH),
5. Cystic fibrosis (CF),
6. Hemoglobin disorders, including Sickle cell anemia (HbSS), Hemoglobin SC disease (HbSC), and Hemoglobin S/β-thalassemia (HbS/βth
7. Galactosemia (GALT)
8. Biotinidase deficiency (BIOT)

Prenatal testing will be covered for medically necessary non-invasive prenatal testing for fetal aneuploidy (trisomy 18, 13, and 21) and prenatal testing for microdeletions.

1. Propionic acidemia
2. Methylmalonic acidemia (methylmalonyl-CoA mutase)

• Telemedicine is the use of interactive audio-video equipment to link practitioners and members located at different sites. The Montana Healthcare Programs Program reimburses providers for medically necessary telemedicine services furnished to eligible members.
• Children’s Special Health Care Services (CSHCS) will help pay for genetic testing for children:
  • https://dphhs.mt.gov/publichealth/cshs/GeneticFinancialAssistance

• BRCA Related Cancer Prior Authorization Criteria
  • https://medicaidprovider.mt.gov/priorauthorization#260626763-brca-related-cancer
  • Children’s Mental Health Bureau Medicaid Services Provider Manual https://dphhs.mt.gov/Portals/85/dsd/documents/CMB/providermanuals/CMHBMedicaidServicesProviderManualjuly2018.pdf
• DME Provider Manual
  • https://medicaidprovider.mt.gov/manuals/durablemedicalequipmentprostheticsorthoticsandmedicalsuppliesmanual
• Montana Healthcare Programs notice: Fetal Chromosomal Aneuploidy Testing
  • https://medicaidprovider.mt.gov/Portals/68/docs/providernotices/2018/provnoticefetalchromosomalaneuploitytesting01302018.pdf
  • https://dphhs.mt.gov/ecfsd/cshs/NewbornScreeningPrograms/metabolicscreening/metabolicscreeninginformation
  • Genetic Testing
    • https://dphhs.mt.gov/ecfsd/cshs/geneticfinancialassistance (https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/heritable disorders/rusp/rusp-uniform-screening-panel.pdf)