Updated on October 12, 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

Cheryl Roberts
Virginia Department of Medical Assistance
600 East Broad Street
Richmond, VA 23219
Phone: (804) 786-8099

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:

  1.  The member must display clinical features, or
  2.  Is at direct risk of inheriting the mutation in question (pre-symptomatic); and
  3. 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


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


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.