Arkansas PASSE Administrative Policy for Molecular Diagnostic Testing (PCR)
This administrative policy governs use of molecular diagnostic testing (MDT) by PCR for members in the Arkansas PASSE program and sets expectations for when PCR testing is medically necessary, coding, and documentation. It affects CareSource providers serving Arkansas PASSE members.
No material clinical or coverage changes in this revision.
Molecular Diagnostic Testing (PCR) Coverage Criteria
MDT (PCR) Coverage Criteria
CareSource covers MDT (PCR) only under specific clinical circumstances and requires conventional, lower-cost testing be used first when appropriate.
ALL of the following
- Use conventional testing first (e.g., rapid antigen, direct fluorescent antibody testing, cultures).
Conventional tests are lower cost and should be utilized before PCR MDT.
If conventional test result
- Positive result: Conventional test is positive: no further PCR testing is medically necessary.
- Negative result with supportive symptoms: Conventional test is negative AND the member's presenting symptoms support the diagnosis (examples: gastroenteritis, streptococcal pharyngitis, acute hepatitis, Shigellosis): MDT by PCR is medically necessary to confirm the diagnosis.
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