New Jersey
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
Jennifer Langer Jacobs, Assistant Commissioner (609)-588-2600
General Genetic Testing Criteria
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
Fee Schedule
BRCA Testing Coverage
Yes
Requirements for BRCA
Genetic testing Panels for High Penetrance Breast Cancer Susceptibility Genes for individuals with a personal history of a BRCA-Related Cancer are proven and medically necessary in the following situations:
1, At least one first- or second-degree relative with a BRCA-Related Cancer; or
2, Ashkenazi Jewish ancestry; or
3. An unknown or Limited Family History A BRCA 1/2 pathogenic mutation detected in tumor tissue; or
4. A personal history of pancreatic cancer; or
5. Men with a personal history of Breast Cancer; or
6. Men with a personal history of metastatic prostate cancer; or
7. Women with a personal history of Ovarian Cancer; or
8. Women with a personal history of Breast Cancer in any of the following situations:
a. Metastatic Breast Cancer; or
b. Breast Cancer diagnosed at age 45 or younger; or
c. An additional Breast Cancer primary (prior diagnosis or bilateral cancer); or
d. Triple-Negative Breast Cancer diagnosed at age 60 or younger;
e. Lobular breast cancer with personal or family history of diffuse gastric cancer
9. Individual has a Tyrer-Cuzick, BRCAPro or Penn11 Score of 2.5% or greater for a BRCA1/2 pathogenic variant.
Genetic testing Panels for High Penetrance Breast Cancer Susceptibility Genes for individuals without a personal history of a related cancer are proven and medically necessary in the following situations:
1. At least one first- or second-degree relative with a BRCA-Related Cancer; or
2. Ashkenazi Jewish ancestry and at least one Close Blood Relative with a BRCA-Related Cancer; or
3. Individual has a Tyrer-Cuzick, BRCAPro or Penn11 Score of 5% or greater for a BRCA1/2 pathogenic variant
Genetic testing Panels for High Penetrance Breast Cancer Susceptibility Genes are unproven and not medically necessary for all other indications including:
1. Screening for cancer risk for individuals not listed in the proven indications above; or
2. Risk assessment of other cancers; or
3. Confirmation of direct to consumer genetic testing without meeting any of the proven indications above.
Cystic Fibrosis Screening
Hereditary Cancer Testing Coverage
Lynch Syndrome Testing Coverage
Yes
Microarray Testing
Newborn Screening
Panel Testing
A Multi-Gene hereditary cancer Panel in individuals with a personal history of a primary solid tumor cancer is proven and medically necessary if all the following criteria are met:
1. The suspected hereditary cancer syndromes can be diagnosed by testing two or more genes included in the specific hereditary cancer panel; and
2. A personal history of at least two different primary solid tumor cancers ; or
3. A personal history of BRCA-related cancer diagnosed at age 40 or younger; or
4. A personal history of BRCA-related cancer and at least one Close Blood Relative with a cancer associated with Lynch Syndrome; or
5. At least one Close Blood Relative diagnosed with a BRCA-Related Cancer at age 40 or younger; or
6. At least two Close Blood Relatives (in addition to affected individual) on the same side of the family diagnosed with any primary solid tumor cancer; or o A personal history of cancer associated with Lynch Syndrome; or
7. A personal history of cancer where tumor testing results demonstrate that the cancer was MSI-high or had immunohistochemical staining showing the absence of one or more mismatch repair proteins (MLH1, MSH2, MSH6 or PMS2); or
8. A personal history of colorectal polyposis with at least 10 adenomatous polyps, at least 2 hamartomatous polyps or at least 5 serrated polyps/lesions proximal to the rectum; or
9. The individual has a PREMM5, MMRpro or MMRpredict Score of 2.5% or greater for having a Lynch syndrome gene mutation.
A Multi-Gene hereditary cancer Panel in individuals without a personal history of a primary solid tumor cancer is proven and medically necessary if all the following criteria are met:
1. The suspected hereditary cancer syndromes can be diagnosed by testing two or more genes included in the specific hereditary cancer Panel; and
2. At least one first-degree relative diagnosed with at least two different primary solid tumor cancers; or
3. At least one first- or second-degree relative diagnosed with a BRCA-Related Cancer at age 40 or younger; or
4. At least three Close Blood Relatives, on the same side of the family, diagnosed with any primary solid tumor cancer; or
5. At least one first-degree relative with a cancer associated with Lynch Syndrome; or
6. At least one second-degree relative with a cancer associated with Lynch Syndrome diagnosed at age 50 or younger; or
7. At least one second-degree relative with at least two cancers associated with Lynch Syndrome; or
8. Two or more second-degree relatives with a cancer associated with Lynch Syndrome; or
9. At least one first- or second-degree relative with a clinical diagnosis of Familial Adenomatous Polyposis, Attenuated Familial Adenomatous Polyposis, Juvenile Polyposis Syndrome or Peutz-Jeghers Syndrome; or
10. The individual has a PREMM5, MMRpro or MMRpredict Score of 5% or greater for having a Lynch syndrome gene mutation.
Genetic testing with a Multi-Gene hereditary cancer Panel in individuals diagnosed with cancer at age 18 or younger is proven and medically necessary.
Multi-Gene hereditary cancer Panels are unproven and not medically necessary for all other indications.
Pharmacogenetic Testing
Prenatal Testing Offered
Whole Exome Sequencing
Other Tests Covered
Other Information
Resources
https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medicaid-comm-plan/nj/genetic-testing-hereditary-cancer-nj-cs.pdf
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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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