Medicare AdvantagePrior AuthMedium impact
Genetic testing services
Blue Cross Blue Shield of Rhode Island·RI · OB-GYN, Family Medicine, Internal Medicine·Physician
Effective date
Jul 1, 2021
We identified it
Jun 19, 2026
Summary
Effective July 1, 2021, genetic testing for Cystic Fibrosis and Spinal Muscular Atrophy no longer requires prior authorization when billed with specific procreative management diagnosis codes for Medicare Advantage and commercial plans. However, genetic testing codes 81513 and 81514 are now non-covered/not medically necessary.
Action Required
Immediately: Billing team must update system to remove prior authorization requirements for CPT codes 81220, 81221, 81222, 81223, 81224, 81443, 81204, 81173, 81174, 81329, 81336, 81337 when billed with diagnosis codes Z31.430, Z41.438, Z31.440, Z31.441, or Z31.448. Stop billing codes 81513 and 81514 for Medicare Advantage and commercial plans as they are now non-covered. Update encounter forms to remind providers of required diagnosis codes for genetic testing authorization exemption.