MedicaidPrior AuthMedium impact
Pharmacogenomics Testing - MEDICAID - KENTUCKY (Revised)
Humana·KY · Psychiatry, Internal Medicine, Family Medicine +5 more·Medicaid
Effective date
Sep 9, 2026
We identified it
Sep 9, 2026
Summary
Humana Kentucky Medicaid updated its pharmacogenomics testing policy effective 09/09/2026, establishing coverage for molecular pathology testing (CPT 81479) when treating patients with medications having known FDA-labeled or CPIC Level A/B gene-drug interactions. The policy explicitly excludes coverage for six specific tests (IFNL3, RightMed variants, ChemoFx, Mind.Px, and SLCO1B1) due to insufficient evidence. Prior authorization is required for all pharmacogenomics testing.
Action Required
By 09/09/2026: Billing team must update prior authorization workflows to require PA for CPT 81479 (unlisted molecular pathology procedure) when used for pharmacogenomics testing in Kentucky Medicaid (Humana Healthy Horizons). Configure billing system to DENY claims for the following excluded codes without exception: 81283, 81328, 81535, 0258U, 0347U, 0348U, 0349U, and 0350U. Providers must document that the medication being considered has a known gene-drug interaction per FDA labeling or CPIC guideline level A or B to support medical necessity. For members under age 21, ensure PA requests include EPSDT medical necessity justification. Update encounter templates and provider education materials to reflect these restrictions. Failure to obtain prior authorization will result in claim denials; billing codes 81283, 81328, 81535, 0258U, 0347U, 0348U, 0349U, and 0350U will be automatically denied.