Whole Genome Sequencing (WGS) Clinical Criteria (CPT 81425, 81426, 814271)

By June 1, 2025, the billing team must: (1) Update the billing system to require prior authorization for all CPT codes 81425, 81426, and 81427 through Arkansas Foundation for Medical Care (AFMC) before claims are submitted; (2) Configure billing software to enforce the one-lifetime-use rule for CPT 81425 and flag any attempts to bill more than once per patient; (3) Update encounter templates and provider order forms to include checkboxes requiring documentation of: qualifying provider type (neonatologist, pediatric intensivist, neurologist, developmental pediatrician, or medical geneticist), genetic counselor certification, clinical utility justification, and exclusion of environmental/non-genetic causes; (4) Train providers and staff on coverage exclusions (autism, developmental delay, prenatal/preimplantation testing, carrier screening); (5) Establish internal tracking to ensure at least two years have passed since WES before ordering WGS for initial cases; (6) Route all WGS prior authorization requests to AFMC at fax (479)-649-0799 or portal https://reviewpoint.afmc.org/s/login/ with required clinical documentation. Claims submitted without prior authorization or missing required documentation will be denied. Providers must document that genetic etiology is the most probable explanation despite prior testing or when invasive procedures are the next step.