MedicaidPrior AuthMedium impact
Rapid Whole Genome Sequencing (rWGS) of Critically Ill Infants - MEDICAID - LOUISIANA (Revised)
Humana·LA · Genetics, Pediatrics, Critical Care·Medicaid
Effective date
Oct 7, 2026
We identified it
Oct 2, 2026
Summary
Humana Louisiana Medicaid now covers Rapid Whole Genome Sequencing (rWGS) for critically ill infants under 12 months in ICU/pediatric units with complex illnesses of unknown genetic etiology. Coverage requires prior authorization, ordering by a medical geneticist or specialist with genetic expertise, mandatory genetic counseling before and after testing, and documentation of specific clinical features (congenital anomalies, abnormal labs, seizures, metabolic abnormalities, or cardiac findings) plus family genetic history. This policy became effective October 7, 2026, with an annual review date of November 4, 2025.
Action Required
Before October 7, 2026: (1) Billing team must configure system to require prior authorization for CPT 81425, 81426, and 81427 for Louisiana Medicaid Healthy Horizons members. (2) Create internal guidelines requiring that claims for these codes include: ordering provider credentials (medical geneticist or neonatologist/pediatric intensivist with genetic expertise), documentation of pre-testing genetic counseling in medical record, and evidence of post-testing genetic counseling submitted with claim. (3) Update prior authorization request templates to verify member age (under 12 months), inpatient ICU/pediatric unit status, and presence of at least ONE clinical feature from the specified list (multiple congenital anomalies, abnormal newborn screen, hyperammonemia, lactic acidosis, refractory hypoglycemia, abnormal therapy response, severe hypotonia, refractory seizures, brief resolved unexplained events, abnormal chemistry suggesting metabolic disorder, or abnormal cardiac findings) plus documented family genetic history. (4) Train billing and prior auth staff on coverage limitations (infection with normal response, confirmed diagnosis, HIE with clear cause, isolated prematurity, TTN, hyperbilirubinemia, nonviable neonate, trauma, meconium aspiration). (5) Claims submitted without required prior authorization, genetic counseling documentation, and clinical feature verification will be denied.