South Dakota

Updated on March 28, 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


State Contact Information

Sarah Aker, South Dakota Medicaid Director

General Genetic Testing Criteria

Diagnostic genetic testing must meet the following criteria:

  1. The recipient displays clinical features of a suspected genetic condition; or
  2. The genetic condition must be associated with a significant medical condition; and
  3. The results of the genetic testing must result in an evidence-based change in the active treatment plan.

Genetic Testing Not Covered

Tests for conditions that are treated symptomatically are not appropriate because the treatment plan would not change as a result of the genetic testing. Genetic testing is not covered to determine the risk of occurrence of the disease in other family members.

State Specific Definition

Genetic Services for Children

Genetic Counseling Requirement

Metabolic Formula Coverage Legislation

Metabolic Formula Coverage & Criteria

Prior Authorization Requirements

Most genetic tests require a prior authorization. To obtain authorization, the provider must complete the applicable genetic testing prior authorization form available on the department’s website. The department will determine whether the test meets the prior authorization criteria.
Some medically necessary genetic tests are covered without a prior authorization. This includes:

  1. Newborn Metabolic Screenings;
  2. Routine Triple/Quad Prenatal Screenings;
  3. Fragile X Screening;
  4. Cologuard; and
  5. Factor V.

Prior Authorization Forms

Fee Schedule

BRCA Testing Coverage

Coverage is available.

Requirements for BRCA

BRCA genetic mutation testing will be covered for breast/ovarian cancer in women and breast cancer in men will be approved in cases where the results will impact the care of the patient.

Cystic Fibrosis Screening

Coverage is available.

Hereditary Cancer Testing Coverage

Coverage is available.

Lynch Syndrome Testing Coverage

Prior authorization coverage includes Lynch syndrome and other inherited colon cancer syndromes for people with a significant risk. Prior authorization must be obtained before the service is provided.

Microarray Testing

Microarray-based Comparative Genomic Hybridization (aCGH) testing is covered with a prior authorization when the criteria below has been met in addition to the general genetic testing criteria. All of the following conditions must be met:

  • Any indicated biochemical tests for metabolic disease have been performed, and results are nondiagnostic.
  • FMR1 gene analysis for (for Fragile X), when clinically indicated, is negative.
  • In addition to a diagnosis of nonsyndromic Developmental Disability, Intellectual Disability, or Autism Spectrum Disorder, the child has one or more of the following:
    • Two or more major malformations.
    • A single major malformation or multiple minor malformations in an infant or child who is also small-for-dates.
    • A single major malformation and multiple minor malformations.
    • The results for genetic testing have the potential to impact clinical management of the patient through an evidence based change to the treatment plan.

Newborn Screening

<p>South Dakota Medicaid covers the newborn metabolic screening panel. The newborn metabolic screening must include the tests specified in SDCL 34-24-18 and ARSD 44:19:01:04. The services are covered under the hospital’s inpatient reimbursement if provided while the newborn is inpatient and must not be billed separately. If the newborn metabolic screening is provided on an outpatient basis, it must be billed using HCPCS S3620. Repeat testing is not separately reimbursable and should not be billed to South Dakota Medicaid.</p>

Panel Testing

Pharmacogenetic Testing

Prenatal Testing Offered

Whole Exome Sequencing

Other Tests Covered

Factor V Leiden testing is covered without prior authorization. For pregnant women, the testing will be covered for a primigravida who also has a first degree relative with a history of thromboembolism and a positive Factor V Leiden test, or if she has had a previous thromboembolism and no previous Factor V Leiden testing. For all other nonpregnant recipients, the testing will be covered if the recipient meets one of the following criteria:

  • Age less than 50 with any venous thrombosis; or
  • Myocardial infarction in female smokers under age of 50; or
  • Recurrent venous thrombosis; or
  • Relatives of individuals with venous thrombosis under age of 50; or
  • Venous thrombosis and a strong family history of thrombotic disease; or
  • Venous thrombosis in women taking oral contraceptives; or
  • Venous thrombosis in unusual sites (such as hepatic, mesenteric, and cerebral veins.

Cologuard (CPT 81528) is covered without prior authorization once every three years for recipients who meet all of the following criteria:

  • Age 50 to 85 years;
  • Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test); and
  • At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or an adenomatous polyp, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).”

Fragile X detection is covered without prior authorization when the recipient meets the following criteria:

  • The individual is age 0 to 20; and
  • The results of the test will affect the individual’s plan of care; and
  • The individual has an intellectual disability, developmental delay, or autism spectrum disorders.

Other Information


  • Professional Services Billing Manual
    • Prior Authorization Manual
  • SD legislature CHAPTER 67:16:42
    • Laboratory and pathology services
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.

The database contains links to third-party websites. These links are provided solely as a convenience to users and not as a guarantee, warrantee, or recommendation by NCC of the content on such third-party websites or as an indication of any affiliation, sponsorship or endorsement of such third party websites. NCC is not responsible for the content of linked third-party sites and does not make any representations regarding the privacy practices of, or the content or accuracy of materials on, such third-party websites. If you decide to access linked third-party websites, you do so at your own risk. Your use of third-party websites is subject to the terms of use for such sites.