Wyoming

Lee Grossman
State Medicaid Agent and Senior Administrator of Div. of
Health Care Financing
Wyoming Department of Health
6101 Yellowstone Road, Suite 210
Cheyenne, WY 82009
Phone: (307) 777-7531

https://medicaiddirectors.org/wp-content/uploads/2023/06/Public_DirectorsList_June2023-1.pdf

Medicaid covers genetic testing under the following conditions:

1. There is reasonable expectation based on family history, risk factors, or symptomatology that a genetically inherited condition exists; AND
2. Test results will influence decisions concerning disease treatment or prevention (in ways that not knowing the test results would not); AND
3. Genetic testing of children might confirm current symptomatology or predict adult-onset diseases and findings might result in medical benefit to the child or as the child reaches adulthood; AND
4. Referral is made by a genetic specialist (codes 81223 and 81224) or a specialist in the field of the condition to be tested; AND
5.  All other methods of testing and diagnosis have met without success to determine the Member’s condition such that medically appropriate treatment can be determined and rendered without the genetic testing.
6. Counseling is provided by healthcare professional with education and training in genetic issues relevant to the genetic tests under consideration.
7. Counselor is free of commercial bias and discloses all (potential and real) financial and intellectual conflicts of interest.
8. Process involves individual or family and is comprised of ALL the following:
   1. Calculation and communication of genetic risks after obtaining 3-generation family history
   2. Discussion of natural history of condition in question, including role of heredity
   3. Discussion of possible impacts of testing (for example, psychological, social, limitations of
      nondiscrimination statutes)
   4. Discussion of possible test outcomes (such as, positive, negative, variant of uncertain significance)
   5. Explanation of potential benefits, risks, and limitations of testing
   6. Explanation of purpose of evaluation (for example, to confirm, diagnose, or exclude genetic condition)
   7. Identification of medical management issues, including available prevention, surveillance, and treatment options and their implications
   8. Obtaining informed consent for genetic test

Yes, it is required. Medicaid covers genetic testing when counseling is provided by healthcare professional with education and training in genetic issues relevant to the genetic tests under consideration (and other conditions are met). Medicaid covers appropriate genetic counseling (96040) when it is provided in conjunction with performance or consideration of medically necessary BRCA testing that meets the criteria listed above.
This includes follow-up genetic counseling to discuss the results of these tests. Three (3) 30-minute units (for a total of 90 minutes) are allowed per day. Genetic counseling services may be billed by a physician when the genetic counselor is under physician supervision and is an employee of the physician. Services provided by independent genetic counselors are not a benefit of Wyoming Medicaid.
Physician specialties that may bill for BRCA genetic counseling are:

• Clinical genetics
• Family practice
• OB/GYN
• Internal medicine
• Internal medicine, medical oncology
• General surgery

Wyoming KidCare CHIP Rules §8

Nutrition therapy is provided in two ways, enteral or parenteral. Since Parenteral nutrition is not considered DME it doesnot require prior authorization.

Enteral nutrition may be covered for the following reasons:

1. When ordered by a physician who has seen the member within 60-day prior for oral nutrition and within 180 days prior for nasogastric, jejunostomy, or gastrostomy tube to ordering the therapy and has documented that the member cannot receive adequate nutrition by dietary adjustments and/or oral supplements. The face-to-face visit requirement is for first time prescriptions and annually thereafter. The face-to-face visit can be completed via telehealth. If an individual goes to a new DME provider, this is considered a first-time prescription.
   Enteral therapy may be given by:
   1. Nasogastric
   2.  Jejunostomy
   3. Gastrostomy tube
   4. Orally
2. Enteral Nutrition Therapy is considered reasonable and necessary for members with:
   1. Functioning gastrointestinal tracts who, due to pathology or non-function of the structures that normally permit food to reach the digestive tract, cannot maintain weight, strength, and overall health status
   2. Oral enteral nutrition therapy is covered if the patient has a diagnosed medical condition such as, but not limited to:
      1. A mechanical inability to chew or swallow solid or pureed or blenderized foods;
      2. A malabsorption inability due to disease of infection;
      3. Weaning from Total Parenteral Nutrition or feeding tube;
      4. A significant weight lost over the past six (6) months or, for children under age 21, has experienced significantly less than expected weight; or
      5. If patient receives less that 75 percent of daily nutrition from a nutritionally complete enteral nutrition product, a nutritionist, speech-language pathologist or a physician must write a detailed plan to decrease
         dependence on the supplement.

Parenteral therapy is covered for members who have a condition of the GI tract that prevents absorption of sufficient nutrients and require IV feedings to sustain life.

Prior Authorization (see Section 6.12 Prior Authorization) is required for all genetic testing codes, except 81420 and 81507.

Yes it is covered.

Medicaid covers BRCA testing when the following criteria are met:

1. Personal or family history of breast cancer, especially if associated with young age of onset, OR
2. Multiple tumors, OR
3.  Triple-negative (such as, estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2-negative) or medullary histology, OR
4. History of ovarian cancer, AND
5. 18 years or older, AND
6. Documentation indicates a genetic counseling visit pre or post testing

Coverage is available.

Coverage is available.

Coverage is available.

Coverage is available.

Coverage is available.

Coverage is available.

https://wyomingmedicaid.com/portal/sites/default/files/inline-files/Manuals_and_Bulletins/Manual_CMS-1500.pdf

https://wymedicaid.telligen.com/wp-content/uploads/2023/07/WY-DME-Manual_TelligenV1_rev1_07.14.2023.pdf

https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/heritable-disorders/reports-recommendations/state-laws-medical-foods-tab.pdf