MedicaidCoverageMedium impact
Thiopurine S-Methyltransferase Enzyme Activity Testing - MEDICAID - VIRGINIA (New)
Humana·VA · Gastroenterology, Rheumatology, Oncology +4 more·Pharmacy
We identified it
Jul 23, 2026
Summary
Virginia Medicaid has issued a new policy establishing coverage guidelines for Thiopurine S-Methyltransferase (TPMT) enzyme activity testing. This test identifies patients with low, intermediate, or high TPMT levels before starting thiopurine therapy (azathioprine, mercaptopurine, thioguanine) to predict myelosuppression risk and guide dosing. Billing teams must verify coverage and prior authorization requirements before submitting claims for this test under Virginia Medicaid plans.
Action Required
Immediately: Billing and clinical teams must review the complete Humana Virginia Medicaid TPMT testing policy at https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a584358 to identify specific billing codes, prior authorization requirements, and medical necessity criteria. Update billing system rules and encounter templates to ensure TPMT testing claims include required documentation (indication for thiopurine therapy, baseline TPMT level interpretation, and dosing recommendations). Contact Humana Virginia Medicaid directly to confirm: (1) exact CPT/HCPCS codes for TPMT testing, (2) prior authorization workflow and timeframes, (3) any age or diagnosis restrictions. Train billing staff on new requirements before processing claims. Establish verification protocol at registration to confirm Virginia Medicaid coverage and obtain prior auth if required. Failure to follow new requirements may result in claim denials or payment delays.