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Genetic Testing for Diagnosis of Inherited Conditions - Medicare Advantage (Revised)
Effective date
Aug 3, 2026
Identified
Aug 4, 2026
Summary
Humana Medicare Advantage updated its genetic testing policy for inherited conditions, effective August 3, 2026. This revision clarifies coverage requirements, references updated MAC-specific LCDs and LCAs by jurisdiction, and defines molecular diagnostic tests (MDTs) and laboratory-developed tests (LDTs) that must meet CMS analytical validity, clinical validity, and clinical utility standards. Billing teams must verify member's MAC jurisdiction and follow corresponding LCD/LCA requirements for genetic testing claims.
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What to do
Action · 6 steps
01Before August 3, 2026: Billing team must update genetic testing billing procedures to align with member's MAC jurisdiction and applicable LCD/LCA requirements.
02Create a reference matrix mapping member ZIP codes to their MAC jurisdiction (J5, J8, J6, JK, J15, JE, JF, JH, JL, JJ, JM, JN).
03For each MAC jurisdiction, download and integrate the current LCD/LCA documents referenced in the policy (e.g., MolDX: Molecular Diagnostic Tests L36807 for J5/J8).
04Update billing software to require verification that genetic testing meets CMS analytical and clinical validity standards and demonstrates clinical utility before claim submission.
05Train billing staff to verify prior authorization requirements per each MAC's specific LCD before processing genetic testing claims, particularly for CPT codes 81265-81268 (STR markers and chimerism).
06Ensure all documentation includes medical necessity and clinical indication for the specific inherited condition being tested.
If missed: Failure to follow MAC-specific requirements will result in claim denials and rework.
Codes mentioned
81265812668126781268
Original notice
Genetic Testing for Diagnosis of Inherited Conditions - Medicare Advantage (Revised)
mcp.humana.com · Always check the source before changing claims.
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