Traditional MedicareCoverageMedium impact
MolDX: Genetic Testing for Hereditary Thrombophilia
Medicare/CMS - LCD·Hematology, Internal Medicine, Genetics·Local Coverage Determination
Effective date
Oct 12, 2026
We identified it
Aug 27, 2026
Summary
WPS Insurance Corporation (MAC Part A/B) is implementing a new Local Coverage Determination (L40274) for MolDX genetic testing related to hereditary thrombophilia, effective October 12, 2026. This policy establishes coverage criteria, medical necessity requirements, and billing guidelines for genetic testing of hereditary clotting disorders. The billing team must review coverage criteria and implement any prior authorization or documentation requirements before the effective date.
Action Required
Before October 12, 2026: (1) Billing team must obtain and review the complete policy text from the CMS Medicare Coverage Database link provided to identify specific CPT/HCPCS codes covered under L40274 for hereditary thrombophilia genetic testing. (2) Determine if prior authorization is required and update billing software accordingly. (3) Update provider encounter documentation templates to capture medical necessity criteria for thrombophilia genetic testing. (4) Train billing and clinical staff on coverage requirements. (5) Communicate policy details to ordering providers, particularly hematology and internal medicine departments. Note: The policy summary provided does not include specific billing codes—access the full policy text at https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=40274&ver=5 to extract exact codes and requirements. Claims submitted without compliance to this LCD may be denied for Traditional Medicare beneficiaries in WPS MAC jurisdiction.