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 Information on GPH should be used for historical reference only.
West 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
Cynthia Beane
Commissioner, Bureau of Medical Services
West Virginia Department of Health and Human Resources
350 Capitol Street, Room 251
Charleston, WV 25301-3706
Phone: (304) 558-1700
https://medicaiddirectors.org/wp-content/uploads/2023/06/Public_DirectorsList_June2023-1.pdf
General Genetic Testing Criteria
Medicaid considers providing genetic testing when all of the following criteria are met:
- The member displays clinical features, or current signs and symptoms, of a genetic condition or is at high risk of inheriting the mutation in question (pre-symptomatic); and
- Clinical studies published in peer-reviewed literature have established strong evidence that the result of the test will directly impact the medical management of the member; and
- The testing method is proven to be scientifically valid and, if testing guidelines exist, the clinical scenario falls within those recommendations; and
- After a history, physical examination, pedigree analysis, genetic counseling (provided from a practitioner with genetic expertise), and completion of conventional diagnostic studies, a definitive
diagnosis remains uncertain; and - Disease-specific criteria are met; and
- Prior authorization from the UMC (if applicable) is obtained
Genetic Testing Not Covered
- Genetic testing or any other testing for the sole convenience of information for the member without impacting treatment; and
- Genetic testing or the medical management of other family members done to benefit the family member(s) rather than benefit the member, unless otherwise specified in policy.
State Specific Definition
Genetic Testing: Involves the analysis of chromosomes, DNA (deoxyribonucleic acid), RNA (ribonucleic acid), genes or gene products to detect inherited or non-inherited genetic variants related to disease or health.
Genetic Services for Children
Genetic Counseling Requirement
Genetic counseling is required prior to genetic testing.
Metabolic Formula Coverage Legislation
No provision.
Metabolic Formula Coverage & Criteria
No provision.
Prior Authorization Requirements
Certain genetic tests require prior authorization. In order to determine medical necessity, all of the following information must be submitted for review to our UMC in addition to any specific criteria
requirements.
- Name of genetic test(s)
- Name of the performing laboratory
- The exact genes(s) and/or variants being tested
- Relevant billing codes
- Brief description of how the genetic test results will guide clinical decisions that would not otherwise be made in the absence of testing
- Medical records related to the genetic test:
- History and physical exam
- Conventional testing and outcomes
- Conservative treatment provided, if any
Prior Authorization Forms
Fee Schedule
BRCA Testing Coverage
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
Newborn Screening
Coverage is provided.
Panel Testing
HLA class I semiquant panel coverage is available.
Pharmacogenetic Testing
Coverage is available.
Prenatal Testing Offered
Coverage is available.
Whole Exome Sequencing
Coverage is available.
Other Tests Covered
Other Information
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.