Rule 1.9: Genetic Testing
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Defines Medicaid coverage, clinical criteria, and prior authorization requirements for genetic testing and pregnancy-related genetic screening for beneficiaries of the Mississippi Division of Medicaid.
New Rule effective 07/01/2026 revises Rule 1.9: Genetic Testing.
Coverage Criteria
inv-01: Diagnostic genetic testing (medical necessity)
Covered when ALL of the following are met
From Rule 1.9.B
inv-02: Pregnancy-related genetic screening
Covered when ALL of the following are met
From Rule 1.9.D
The Division of Medicaid does not cover genetic testing or screening when they are considered experimental, investigational, or unproven. Coverage is also excluded for testing performed for the purpose of determining ancestry, as well as for other uses that are not diagnostic in nature.
Tests performed solely to determine an individual’s ancestry or for purposes that are not diagnostic are explicitly not covered under this policy.
Covered Indications
inv-14: Establishing diagnosis when clinical features suggest a genetic disorder and prior conventional diagnostics are inconclusive, and results will impact clinical management.
Covered indication
inv-15: Pregnancy-related genetic screening meeting the specified conditions (not previously performed in same pregnancy and informed consent not declined).
Covered indication per Rule 1.9.D
Coding
| No codes listed |
Provider Actions & Requirements
Prior authorization required
Prior authorization is required for genetic testing and genetic screening procedures as determined by the Division of Medicaid.
Ordering and prior-testing requirement
Conventional diagnostic studies must have been completed without yielding a definitive diagnosis before diagnostic genetic testing is covered; ensure documentation shows prior testing and clinical rationale.
Required supporting documentation for medical necessity
Documentation must show (1) the beneficiary has significant clinical features suggestive of a genetic disorder, (2) the test result will directly impact clinical management and guide treatment, and (3) conventional diagnostic studies were completed but a definitive diagnosis remains uncertain.
Denial triggers — not covered uses
Claims for genetic testing or screening may be denied when the service is considered experimental, investigational, or unproven; when performed for ancestry determination; or when used for non-diagnostic purposes.
Informed decision and documentation for pregnancy-related screening
Before pregnancy-related genetic screening, the beneficiary must receive all necessary information to make an informed decision and documentation must show the beneficiary did not decline the screening.
- Provide counseling/information about the screening as part of prenatal care.
- Document that information was provided and that the beneficiary did not decline.
Limit tests to diagnostic indications and pregnancy-related screening
Ensure samples and orders are limited to diagnostic purposes consistent with Rule 1.9 definitions and coverage criteria; tests ordered solely to determine ancestry or for other non-diagnostic reasons are not covered and may be denied.
Definitions
Eligibility Requirements
Eligibility for genetic testing and pregnancy-related genetic screening is governed by the medical necessity and coverage criteria in this policy, including the diagnostic criteria for genetic testing, the pregnancy-related screening conditions, and any applicable prior authorization requirements.
Prior to coverage of diagnostic genetic testing, conventional diagnostic studies must have been completed without yielding a definitive diagnosis. Genetic testing is covered only when results are needed to establish a diagnosis that will directly impact clinical management.
Not Covered
This policy excludes genetic tests that are experimental, investigational, or unproven, tests performed to determine ancestry, and tests conducted for other non-diagnostic purposes.
Background
Genetic testing is distinct from genetic screening: genetic testing is performed to confirm or rule out suspected genetic disorders and is covered when medically necessary to establish a diagnosis that will affect clinical management, particularly after conventional diagnostics are inconclusive. Genetic screening identifies risk and, for pregnancy-related screening, is covered only when it has not been performed previously in the same pregnancy and the beneficiary received necessary information and did not decline the screening.
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