MedicaidCoverageMedium impact
Update to “New Genetic Testing Benefits for Texas Medicaid Effective May 1, 2026”
Texas Medicaid·TX · Oncology, Hematology·General
Effective date
May 1, 2026
We identified it
May 7, 2026
Summary
Texas Medicaid updated limitations for ClonoSEQ genetic testing (procedure code 0364U) to allow six tests per rolling year by any provider, with additional tests possible through medical necessity appeals. This change is effective May 1, 2026.
Action Required
By May 1, 2026: Billing team must update system to allow up to 6 units of procedure code 0364U per rolling year for Texas Medicaid patients. Update encounter forms to track frequency and inform providers that additional tests beyond 6 require appeal with medical necessity documentation. Contact member's specific MCO for administrative requirements.