MedicaidCoverageMedium impact
Whole Genome Sequencing (WGS) Clinical Criteria (CPT 81425, 81426, 814271)
Arkansas Medicaid·AR · Genetics, Oncology, Pediatrics +2 more·Coding
Effective date
May 22, 2026
We identified it
May 22, 2026
Summary
Arkansas has updated clinical criteria for Whole Genome Sequencing (WGS) billing codes CPT 81425, 81426, and 81427. This is a brand new policy effective immediately that establishes specific medical necessity requirements for these genetic testing procedures. Billing teams must review the detailed clinical criteria document to understand what documentation and patient scenarios qualify for coverage before submitting claims.
Action Required
Immediately: Obtain and review the complete Arkansas policy document at https://humanservices.arkansas.gov/wp-content/uploads/ON-017-26.docx to identify the specific clinical criteria for WGS billing. Genetics providers and billing staff must update claim submission workflows to ensure CPT 81425, 81426, and 81427 are only billed when patient cases meet the stated clinical criteria. Add internal documentation checklist for WGS cases to the EMR or billing system. Notify all providers performing genetic testing of the new requirements. Begin applying these criteria to all WGS claims submitted after May 22, 2026. Claims submitted without documented medical necessity meeting Arkansas criteria will face denial.