From 2004 to 2024, the Health Resources and Services Administration (HRSA) funded the National Coordinating Center for the Regional Genetics Networks (NCC). NCC developed and maintained the Genetics Policy Hub.
With the conclusion of NCC funding, the Genetics Policy Hub (GPH) will no longer be updated or maintained. Information on GPH should be used for historical reference only.
Virginia
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
Cheryl Roberts
Director
Virginia Department of Medical Assistance
600 East Broad Street
Richmond, VA 23219
Phone: (804) 786-8099
https://medicaiddirectors.org/wp-content/uploads/2023/06/Public_DirectorsList_June2023-1.pdf
General Genetic Testing Criteria
DMAS considers genetic testing medically necessary to establish a molecular diagnosis of an inheritable disease when all of the following are met:
- The member must display clinical features, or
- Is at direct risk of inheriting the mutation in question (pre-symptomatic); and
- The result of the test will have a direct impact on the treatment being delivered to the member.
It is up to the primary physician to ensure that the aforementioned criteria are met for coverage of these tests. If these criteria are not met on retrospective review of claims by DMAS, then the payment for the physician and all related laboratory claims will be recovered.
Genetic Testing Not Covered
State Specific Definition
Genetic Services for Children
Genetic Counseling Requirement
No genetic counselor licensure requirement.
Genetic counseling is required prior to genetic testing.
Metabolic Formula Coverage Legislation
Virginia 12 VAC 5‐71‐10 et seq.
Metabolic Formula Coverage & Criteria
Virginia 12 VAC 5‐71‐10 et seq.
Prior Authorization Requirements
The fee schedule indicates which genetic tests require PA.
Prior Authorization Forms
Fee Schedule
BRCA Testing Coverage
Yes, coverage is available.
Requirements for BRCA
Cystic Fibrosis Screening
Coverage is available.
Hereditary Cancer Testing Coverage
Coverage is available.
Lynch Syndrome Testing Coverage
Coverage is available.
Microarray Testing
Coverage is available.
Newborn Screening
The test kit and actual laboratory test would be part of the initial newborn hospital facility charges and reimbursed to the facility under the established facility reimbursement, if done with the hospitalization of the birth, the actual laboratory blood test would be billed by the performing laboratory using CPT code 84030- Phenylalanine.
Panel Testing
Coverage is available.
Pharmacogenetic Testing
Coverage is available.
Prenatal Testing Offered
Covered
Whole Exome Sequencing
Coverage is available.
Other Tests Covered
Other Information
When looking at the fee schedule, it will identify a numeric value for the field PA_TYPE, one of the following:
00 No PA required
01 Always needs a PA
02 Only needs PA if service limits are exceeded
03 Always needs PA, with per frequency
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.
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.