MedicaidCoverageLow impact
Genetic Testing for Diagnosis of Inherited Conditions - MEDICAID - SOUTH CAROLINA (Revised)
Humana·SC · Genetics, Hematology, Oncology +2 more·Medicaid
Effective date
Aug 26, 2026
We identified it
Aug 25, 2026
Summary
Humana updated its South Carolina Medicaid policy for genetic testing used to diagnose inherited conditions. The policy establishes coverage criteria for molecular pathology testing (CPT 81479) and multianalyte assays with algorithmic analysis (CPT 81599), requiring that tests demonstrate analytic validity, clinical validity, clinical utility based on peer-reviewed evidence, and must change clinical management. This is a routine annual review update effective August 26, 2026, with no substantive coverage changes from prior versions.
Action Required
Before August 26, 2026: Billing team should review the coverage criteria for CPT 81479 (Unlisted molecular pathology procedure) and CPT 81599 (Unlisted multianalyte assay with algorithmic analysis) in the South Carolina Medicaid billing system. Ensure that claims for these codes include documentation supporting analytic validity, clinical validity, clinical utility based on peer-reviewed medical literature, and evidence that results will change clinical management per specialty society recommendations. For members under age 21, verify that medical necessity is documented in accordance with EPSDT (Early and Periodic Screening, Diagnostic and Treatment) requirements. No immediate action is required; this is a delayed-effective update for reference and system verification.