MedicaidCoverageMedium impact
Genetic Testing for Diagnosis of Inherited Conditions - MEDICAID - INDIANA (Revised)
Humana·IN · Genetics, Neurology, Hematology +3 more·Medicaid
Effective date
Aug 26, 2026
We identified it
Aug 25, 2026
Summary
Humana Indiana Medicaid has revised its genetic testing policy for inherited conditions (Policy HUM-IN-2109-003), effective 08/26/2026. The policy establishes specific coverage criteria and approved testing strategies for five inherited genetic conditions: adrenoleukodystrophy, hemophilia B, molecular pathology testing, myotonic dystrophy types 1 and 2, and Tay-Sachs disease. Billing teams must implement coverage limitations that restrict certain tests (e.g., full DMPK/CNBP sequence analysis) and enforce pre- and post-test genetic counseling requirements.
Action Required
By 08/26/2026, the billing team must: (1) Update billing system rules to enforce pre- and post-test genetic counseling documentation requirements for all covered genetic tests; (2) Implement coverage limitations in the system to DENY claims for CNBP full gene sequence analysis (DM2) and DMPK full sequence analysis (DM1) outside of targeted variant analysis for repeat expansions; (3) Create billing rules that require documented medical necessity for molecular pathology testing (CPT 81479) per specialty society recommendations before claims are submitted; (4) Update prior authorization workflows to verify eligibility criteria are met for each condition (e.g., carrier screening, abnormal lab results, symptomatic presentation) before billing codes 81238 (F9 gene testing), 81479 (molecular pathology), 83080 (beta-hexosaminidase), or S3853 (myotonic dystrophy testing); (5) Train billing and authorization staff on the five covered conditions and their specific testing criteria to prevent denials. Claims submitted without meeting documented criteria will be denied by Humana Indiana Medicaid.