Medicare AdvantageCoverageMedium impact
Genetic Testing for Diagnosis of Inherited Conditions - Medicare Advantage (Revised)
Humana·Genetics, Internal Medicine, Pediatrics +5 more·Medicare Advantage
Effective date
Sep 1, 2026
We identified it
Aug 29, 2026
Summary
This is a Medicare Advantage policy revision for genetic testing used to diagnose inherited conditions, effective September 1, 2026. The policy establishes coverage requirements for genetic tests (single gene, multigene panels, WGS, WES, and STR analysis) when used diagnostically in symptomatic patients, and references MAC-specific Local Coverage Determinations and Articles that govern billing, coding, and prior authorization requirements by geographic region.
Action Required
By August 31, 2026: Billing team must review and implement the applicable MAC-specific Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) for your geographic region listed in the policy document (covering MACs J5, J6, J8, J15, JE, JF, JH, JJ, JL, JM, JN). Update billing system rules, prior authorization workflows, and coding guidelines to align with regional MAC requirements for genetic testing. Identify which MAC jurisdiction your practice falls under and obtain the specific LCD/LCA documents from CMS to ensure accurate coding for CPT codes 81265-81268 (STR markers and chimerism) and other genetic testing codes. Implement any required prior authorization processes specified in your regional MAC's LCD. Failure to follow MAC-specific requirements will result in claim denials. Contact your MAC directly or review L36807, A57772, L39987, L35000, L36021, L35160, L35062, L35025, L39084, and L34519 (region-dependent) for specific billing and coding instructions.