Nevada

Updated on March 9, 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

Suzanne Bierman, Administrator of Nevada Department of Health and Human Services Division of Health Care Financing and Policy
1100 East William Street, Suite 101
Carson City, NV 89701
(775) 684-3676

General Genetic Testing Criteria

Genetic Testing Not Covered

Gene expression profiling, except when it is medically necessary as a prognostic assay to identify recipients diagnosed with breast cancer who are likely to respond to systemic chemotherapy when utilizing Oncotype DX TM.

Molecular testing except for BRCA1/BRCA2 testing services for:

Individuals without a personal history of breast and/or ovarian cancers, considered to be high risk as defined in Policy Attachment #08-01 or as otherwise defined by the US Preventive Services Task Force;
Women with a personal history of breast and/or ovarian cancer with a personal history of breast cancer as defined in Policy Attachment #08-01 or as otherwise defined by the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines; or
Men with a personal history of breast cancer as defined in Policy Attachment #08-01 or as otherwise defined by the NCCN Clinical Practice Guidelines.

State Specific Definition

Genetic Services for Children

Genetic Counseling Requirement

Genetic counseling must precede genetic testing for hereditary cancer.

Metabolic Formula Coverage Legislation

Nevada Revised Statutes
Chapter 695B – Nonprofit Corporations for Hospital, Medical and Dental Service
NRS 695B.1923 – Required provision concerning coverage for treatment of certain inherited metabolic diseases. by the patient during the length of stay.

Metabolic Formula Coverage & Criteria

Prior Authorization Requirements

The ordering physician must obtain prior authorization for the following services, except for Medicare/Medicaid dual eligible recipients who are still eligible for Medicare benefits:

Genotype and phenotype assay testing for recipients with chronic HIV infection prior to initiation of highly active antiretroviral therapy; or
Laboratory tests referred by a physician office laboratory directly to an out of state laboratory.

Prior Authorization Forms

https://www.medicaid.nv.gov/providers/priorauth/referencelists.aspx

Fee Schedule

http://dhcfp.nv.gov/Resources/Rates/FeeSchedules/

BRCA Testing Coverage

Coverage is available.

Requirements for BRCA

Coverage is available for:

BRCA1/BRCA2 testing services for individuals without a personal history of breast and/or ovarian cancer should be provided to high risk individuals.
BRCA1/BRCA2 testing services for women with a personal history of breast and/or ovarian cancer and for men with a personal history of breast cancer.
If the mutation in the family is known, only the test for that mutation is covered. For example, if a mutation for BRCA1 has been identified in a family, a single site mutation analysis for that mutation is covered, while a full sequence BRCA1 and BRCA2 analyses is not. An exception to this can be considered if a Certified Genetic Counselor presents sufficient justifiable need.
If the individual is of Ashkenazi Jewish descent, test the three common mutations first. Then if negative, consider comprehensive (“Reflex”) testing based on assessment of individual and family history as if the individual is of non-Ashkenazi Jewish descent.
Frequency is limited to once in a lifetime.

Cystic Fibrosis Screening

Hereditary Cancer Testing Coverage

Coverage for Breast cancer famlial variants is available.

Lynch Syndrome Testing Coverage

No coverage is available.

Microarray Testing

Newborn Screening

<p>Except for specific laboratory tests identified under non-covered services, the Division of Health Care Financing and Policy (DHCFP) reimburses organ or disease oriented panels, therapeutic drug assays, evocative/suppression testing, clinical pathology consultations, urinalysis, chemistry, hematology and coagulation, immunology, tissue typing, transfusion medicine, microbiology, cytopathology, cytogenic, surgical pathology, total transcutaneous bilirubin and tests specified under, “Other Procedures” in the most recent version of Current Procedural Terminology (CPT).</p> <p>Follow-up testing performed by either the discharging hospital laboratory and/or the newborn’s physician for newborns discharged with a hyperbilirubinemia diagnosis.</p>

Panel Testing

Pharmacogenetic Testing

Prenatal Testing Offered

Whole Exome Sequencing

Other Tests Covered

The Oncotype DXTM is considered medically necessary for eligible participants with diagnosed breast cancer as a prognostic assay to identify who is most likely to respond to systemic chemotherapy.

Other Information

Resources

MSM CHAPTER 800 – LABORATORY SERVICES
- http://dhcfp.nv.gov/Resources/AdminSupport/Manuals/MSM/C800/Chapter800/
MSM Chapter 1300 DME, Disposable Supplies and Supplements
- http://dhcfp.nv.gov/Resources/AdminSupport/Manuals/MSM/C1300/Chapter1300/
- https://law.justia.com/codes/nevada/2015/chapter-695b/statute-695b.1923/

Newborn Screening Reimbursement

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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