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Genetic Testing for Hereditary Cardiovascular Disease - Medicare Advantage (Revised)
Act
by Jun 30, 2026
Effective date
Jul 1, 2026
Identified
Jun 30, 2026
Summary
This is a Medicare Advantage policy revision (effective 07/01/2026) that establishes coverage criteria for genetic testing in hereditary cardiovascular disease, including inherited cardiomyopathies, channelopathies, familial hypercholesterolemia, and Marfan syndrome. The policy references MAC-specific LCDs and LCAs across multiple jurisdictions and requires adherence to CMS analytical/clinical validity and clinical utility standards for molecular diagnostic tests (MDTs) and laboratory-developed tests (LDTs).
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What to do
by Jun 30, 2026 · 6 steps
01Billing team must review and update billing system rules to align genetic testing submissions with the MAC-specific LCDs and LCAs referenced in this policy.
02Identify which MAC jurisdiction(s) your practice operates in (J5, J8, J6, JK, J15, JE, JF, JH, JL, JJ, JM, or JN based on state location).
03Obtain the specific LCD/LCA documents from CMS for your jurisdiction to identify covered tests, required medical necessity documentation, and applicable CPT/HCPCS codes.
04Ensure that all genetic testing for cardiomyopathies, channelopathies, familial hypercholesterolemia, and Marfan syndrome includes proper clinical documentation demonstrating medical necessity per CMS requirements.
05Update encounter templates and prior authorization workflows to capture required clinical indicators (e.g., family history, clinical presentation, abnormal cardiac findings).
06Train providers and clinical staff on documentation requirements.
If missed: Failure to comply with MAC-specific LCD/LCA requirements will result in claim denials or recoupment.
Original notice
Genetic Testing for Hereditary Cardiovascular Disease - Medicare Advantage (Revised)
mcp.humana.com · Always check the source before changing claims.
Related changes
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