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Genetic Testing for Diagnosis of Inherited Conditions - Medicare Advantage (Revised)
Act
by Aug 31, 2026
Effective date
Sep 1, 2026
Identified
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.
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What to do
by Aug 31, 2026 · 6 steps
01Billing 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).
02Update billing system rules, prior authorization workflows, and coding guidelines to align with regional MAC requirements for genetic testing.
03Identify 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.
04Implement any required prior authorization processes specified in your regional MAC's LCD.
05Failure to follow MAC-specific requirements will result in claim denials.
06Contact your MAC directly or review L36807, A57772, L39987, L35000, L36021, L35160, L35062, L35025, L39084, and L34519 (region-dependent) for specific billing and coding instructions.
Codes mentioned
81265812668126781268
Original notice
Genetic Testing for Diagnosis of Inherited Conditions - Medicare Advantage (Revised)
mcp.humana.com · Always check the source before changing claims.
Related changes
See all Humana changes →Genetic Testing for Diagnosis of Inherited Conditions - Medicare Advantage (Revised)MediumEffective Aug 3, 2026 · Medicare AdvantageGenetic Testing for Diagnosis of Inherited Conditions - Medicare Advantage (Revised)MediumEffective Mar 2, 2026 · Medicare AdvantageGenetic Testing for Diagnosis of Inherited Conditions - MEDICAID - KENTUCKY (Revised)MediumEffective Sep 23, 2026 · MedicaidGenetic Testing for Diagnosis of Inherited Conditions - Medicare Advantage (Revised)MediumNo effective date · Medicare AdvantageBrowse every Humana change in the policy list