MedicaidCoverageHigh impact
Whole Exome Sequencing (WES) Clinical Criteria (CPT 81415, 81416, 81417)
Arkansas Medicaid·AR · Genetics, Oncology, Cardiology +3 more·Coding
Effective date
May 22, 2026
We identified it
May 22, 2026
Summary
Arkansas has issued new clinical criteria for Whole Exome Sequencing (WES) billing under CPT codes 81415, 81416, and 81417. This is a fresh policy update (1 day old) that establishes procedural coding requirements and likely clinical necessity thresholds for WES testing. The billing team must obtain and review the full policy document to understand specific clinical criteria, prior authorization requirements, and documentation needs.
Action Required
By June 5, 2026: Billing team must immediately download and review the complete WES clinical criteria policy from Arkansas Department of Human Services (ON-016-26.docx). Identify specific clinical criteria, prior authorization requirements, and documentation standards for CPT 81415, 81416, and 81417. Update billing system validation rules and encounter forms to enforce the new requirements. Notify all providers and genetic counselors of the new clinical criteria. Implement any required prior authorization workflows. Failure to comply will result in claim denials for WES testing that does not meet the new Arkansas clinical criteria.