New Genetic Testing Benefits for Texas Medicaid Effective May 1, 2026
AI Summary
Texas Medicaid is adding new genetic testing benefits effective May 1, 2026, including whole exome sequencing, FoundationOne cancer testing, transplant rejection monitoring, ClonoSEQ testing for blood cancers, enhanced liver fibrosis testing, and breast cancer index testing. All these new tests require prior authorization and have specific medical necessity criteria and frequency limitations.
Action Required
By May 1, 2026: Billing team must update system to require prior authorization for all new genetic testing codes (81415, 81416, 81417, 0037U, 0239U, 81595, 0493U, 0540U, 0364U, 81517, 81518). Update encounter forms with lifetime limits and age restrictions for each test. Train providers on medical necessity criteria and frequency limitations. Add required diagnosis codes for ClonoSEQ, enhanced liver fibrosis, and breast cancer index testing to billing system edits.
Affected Billing Codes
Plan Types
Medicaid
States
TX
Specialties
oncology, cardiology, gastroenterology, ob-gyn, pediatrics, laboratory