Genetic Testing: Once per Lifetime
Customize your policy alerts
Sign up for Amerigroup Policy G-23002 alerts
Get alerted when Policy G-23002 changes without checking for updates manually.
Monitor payer policy activity
Defines Amerigroup's reimbursement policy that specific germline genetic sequencing procedures are payable only once per member's lifetime and applies to providers submitting claims for covered members under the listed Georgia programs.
Updated Related Coding section by adding new codes.
Reinterpretation of original results is not separately reimbursable.
Coverage Criteria
Once-per-lifetime sequencing and reimbursement limitation
Covered when ALL of the following are met
Applies to the genetic procedures indicated in the Related Coding section; the germline genotype does not change during the member's lifetime.
Although variant classifications may change over time, repeat sequencing is not required and reinterpretation/re-analysis of previously obtained sequence data should not be billed as a separate reimbursable procedure.
Reinterpretation of previously obtained germline sequencing results is not payable as a separate service. The plan considers reinterpretation or re-analysis of original sequence data part of the original testing episode and is not separately reimbursable.
Related Coding
| No codes listed |
Provider Actions & Billing Requirements
Authorization and medical necessity requirement
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member's state of residence.
Operational billing and coding check
Use industry-standard, compliant codes on all claim submissions and follow any operational updates in the Related Coding section prior to billing.
- Check the Related Coding section for newly added procedure codes before submitting claims.
Billing documentation requirement
Services should be billed with Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and/or revenue codes and must be fully supported in the medical record and/or office notes.
Billing noncompliance consequences
If appropriate coding/billing guidelines or current reimbursement policies are not followed, the claim may be rejected or denied, payment may be recovered/recouped, or reimbursement may be adjusted.
- Reject or deny the claim.
- Recover and/or recoup claim payment.
- Adjust reimbursement to reflect the appropriate services and/or procedures performed.
Background
Germline (hereditary) genotype does not change during a member’s lifetime; sequencing determines the nucleotide sequence and identifies variants, but variant classifications may be recategorized over time. Because the underlying germline sequence remains stable, repeat sequencing is not required for later reinterpretation or re-analysis of previously obtained germline sequence data. Providers should therefore note that reinterpretation of results reflects evolving evidence and does not by itself justify a new sequencing procedure.
Definitions
Not Covered
Repeat sequencing of a member’s germline genotype for the purpose of obtaining a new sequence is limited to once per lifetime. Reinterpretation of the original results does not constitute a separate reimbursable procedure and should not be billed as an additional service.
Revision History
Policy effective date for the updated Related Coding and once-per-lifetime sequencing limitation became 2026-07-01.
Review approved and Related Coding section updated by adding new procedure codes relevant to the once-per-lifetime sequencing policy.
Initial approval of the policy (initial effective 02/01/2024) establishing the once-per-lifetime sequencing limitation and non‑reimbursability of reinterpretation.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.