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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyWellpoint Genetic Testing Policy Update | OpenPaye…
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    CurrentWellpointPolicy G-23002

    Genetic Testing: Once per Lifetime

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    This policy governs reimbursement for specified germline genetic sequencing procedures for Wellpoint Tennessee Medicaid members. The procedures are limited to once per member lifetime, and reinterpretation of previously generated results is not separately reimbursable unless provider, state, or federal requirements indicate otherwise.

    Policy Summary
    PayerWellpoint Tennessee Medicaid
    PolicyGenetic Testing: Once per Lifetime
    Policy CodePolicy G-23002
    Change TypeCoding update
    Effective DateFebruary 1, 2027
    Next Review DateNot specified
    Key ActionDo not submit repeat sequencing of a member's germline genotype for future interpretation or re-analysis of previously sequenced data.
    SourceLink
    POLICY UPDATE CHANGES

    The Related Coding section was updated by adding codes.

    Once per lifetimeLimit for specified genetic sequencing procedures
    Not separately reimbursableReinterpretation of original genetic testing results
    No balance billingProvider billing restriction resulting from this policy
    Claim action possibleClaims may be rejected, denied, recouped, or adjusted when requirements are not followed

    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.

    Genetic Sequencing Reimbursement Criteria

    Genetic sequencing reimbursement criteria

    Reimbursement is allowed when all of the following criteria are met, subject to applicable contractual and regulatory requirements.

    ALL of the following

    • The service is one of the specific genetic procedures identified in the Related Coding section.
    • The procedure has not previously been reimbursed for the member during the member's lifetime.Once per member lifetime
    • The service is not solely reinterpretation of original genetic test results; reinterpretation is not separately reimbursable.
    • Provider, state, or federal contracts and/or requirements do not indicate otherwise.

    Applicable Procedures and Frequency Limits

    Genetic sequencing once per lifetime proceduresmixedCovered
    No codes listed
    Lifetime sequencing limit
    Sequencing frequencyOnce per member lifetime
    Repeat sequencingNot required for future interpretation of a germline genotype or re-analysis of previously sequenced data
    ReinterpretationReinterpretation of original results is not separately reimbursable

    Billing and Documentation Requirements

    Denial Risk

    Avoid repeat germline sequencing

    Do not submit repeat sequencing of a member’s germline genotype when the purpose is future interpretation or re-analysis of previously sequenced data.

    Documentation Required

    Support claims with documentation and medical necessity

    Submit claims using compliant codes and documentation that fully support the services performed. Services must also meet applicable authorization and medical-necessity requirements appropriate to the procedure, diagnosis, and member’s state of residence.

    • Use proper billing and submission guidelines, including industry-standard compliant codes.
    • Ensure billed services are fully supported in the medical record and/or office notes.

    Genetic Testing Terms

    Germline
    DefinitionCells arising from germ cells that contain genetic code that may be passed down to future generations
    Alternate terminologyMay also be referred to as hereditary or constitutional
    Inheritance relevanceThe genetic code in germline cells may be passed to future generations
    Genotype
    DefinitionAn individual's unique set of all the genes
    ScopeThe genotype refers to the complete set of genes in an individual organism
    Policy context
    Policy Summary
    PayerWellpoint Tennessee Medicaid
    PolicyGenetic Testing: Once per Lifetime
    Policy CodePolicy G-23002
    Change TypeCoding update
    Effective DateFebruary 1, 2027
    Next Review DateNot specified
    Key ActionDo not submit repeat sequencing of a member's germline genotype for future interpretation or re-analysis of previously sequenced data.
    SourceLink
    On This Page
    Genetic Sequencing Reimbursement CriteriaApplicable Procedures and Frequency LimitsBilling and Documentation RequirementsGenetic Testing Terms
    Billing Rule

    Do not balance bill members

    Do not balance bill members based on the once-per-lifetime reimbursement policy.

    Denial Risk

    Noncompliant claims may be denied or adjusted

    Failure to follow applicable coding, billing, and reimbursement policies may result in claim rejection or denial, recovery or recoupment of payment, or adjustment of reimbursement.

    • Claims may be rejected or denied.
    • Claim payment may be recovered or recouped.
    • Reimbursement may be adjusted to reflect the services and procedures performed.
    The germline genotype does not change during a member's lifetime
    Sequencing
    DefinitionDetermining the identity of each nucleotide in a DNA segment to identify the genetic information carried in that segment
    NucleotidesNucleotides are the four chemical building blocks, called bases, that make up DNA
    PurposeSequencing identifies the kind of genetic information carried in a particular DNA segment
    Variant
    DefinitionA nucleotide deviation from a reference DNA sequence
    Classification categoriesVariants may be classified as pathogenic, likely pathogenic, variant of uncertain or unknown significance (VUS), likely benign, or benign
    Classification changesAs evidence evolves, previous classifications may later require modification