MedicaidPrior AuthHigh impact
Genetic Testing for Diagnosis of Inherited Conditions - MEDICAID - MICHIGAN (Revised)
Humana·MI · Genetics, Neurology, Ophthalmology +3 more·Medicaid
Effective date
Aug 26, 2026
We identified it
Aug 25, 2026
Summary
Humana Michigan Medicaid has updated its genetic testing coverage policy for inherited conditions, effective 08/26/2026. The policy establishes specific medical necessity criteria, coding requirements, and pre/post-test genetic counseling mandates for nine inherited genetic conditions including adrenoleukodystrophy, corneal dystrophy, muscular dystrophies, and glycogen storage disease. Billing teams must implement these criteria into authorization workflows and ensure providers document required clinical findings before genetic testing claims are submitted.
Action Required
Before 08/26/2026: Billing team must update prior authorization system to enforce Humana Michigan Medicaid genetic testing requirements for all nine covered conditions (adrenoleukodystrophy, corneal dystrophy, DRPLA, GSD I, molecular pathology, myotonic dystrophy types 1-2, oculopharyngeal muscular dystrophy, STR analysis, and spinal/bulbar muscular atrophy). For each condition, configure system to require: (1) Pre- and post-test genetic counseling documentation, AND (2) condition-specific clinical criteria per policy (e.g., abnormal VLCFA results + white matter abnormalities for adrenoleukodystrophy; ophthalmology exam findings for corneal dystrophy; at least 2 clinical signs for DRPLA and GSD I). Update encounter forms and provider templates to include mandatory clinical documentation fields. Train providers and billing staff on specific coding requirements (CPT 81333 for TGFBI gene, 81177 for ATN1 CAG expansion, 81250 for G6PC gene). Claims submitted without documented pre-test counseling, required clinical findings, or genetic counseling documentation will be denied. Implement deadline: 30 days before effective date.