Genetic Testing Policy, Codes and Fee Updates
Effective for dates of service on or after Dec. 1, 2024, the South Carolina Department of Health and Human Services (SCDHHS) is updating its genetic testing policy, coverage and the Independent Lab and Radiology Fee Schedule.
Genetic tests are covered for full-benefit Healthy Connections Medicaid members who meet the clinical criteria that renders these tests medically necessary. Clinical criteria and coverage limitations for specific genetic tests including EpiSign Complete, whole exome sequencing, whole genome sequencing and several hereditary conditions; as well as the updated policy for the post-transplant gene expression test and overall genetic testing policy are listed here. These updated policies, criteria and coverage limitations will also be published in the Physicians Services Provider Manual by Dec. 1, 2024.
SCDHHS will update the Independent Lab and Radiology Fee Schedule, by Dec. 1, 2024, to reflect the updated procedure codes covered by Healthy Connections Medicaid and their respective rates listed in the table below.
| Procedure Code | Test Description | Rate |
|---|---|---|
| 0318U | EpiSign Complete | $1,380.97 |
| 81415 | Whole exome sequencing | $3,728.40 |
| 81416 | Whole exome comparator sequence analysis | $9,360.00 |
| 81417 | Exome reanalysis | $249.60 |
| 81427 | Genome reanalysis | $1,823.37 |
| 81425 | Whole genome sequencing | $3,924.34 |
| 81426 | Whole genome comparator sequence analysis | $2,113.76 |
| 81161 | DMD deletion/duplication analysis | $217.62 |
| 81234 | DMPK expansion analysis | $106.86 |
| 81336 | SMN1 full sequencing | $235.05 |
| 81329 | SMN1 deletion/duplication | $106.86 |
| 81337 | SMN1 known familial variant | $144.46 |
| 81222 | CFTR deletion/duplication | $339.35 |
| 81221 | CFTR known familial variant | $75.83 |
| 81223 | Sequencing of CFTR gene | $389.22 |
| 81431 | Hearing loss panel, deletion/duplication analysis, including Usher syndrome, Pendred syndrome | $530.06 |
| 81411 | Aortic dysfunction or dilation panel, deletion/duplication analysis, including but not limited to TGFBR1, TGFBR2, MYH11 and COL3A1 | $1,053.15 |
| 81265 | Maternal cell contamination studies | $181.79 |
| 81204 | X-inactivation studies | $106.86 |
| 81410 | Aortic dysfunction/dilation & related disorders NGS panel, connective tissue disorders NGS panel, sequencing analysis | $393.12 |
| 81413 | Long QT syndrome NGS panel, comprehensive cardiac NGS panel, sequencing analysis | $456.22 |
| 81414 | Cardiac ion channelopathies (del/dup) | $456.22 |
| 81419 | Epilepsy/seizure NGS panel | $1,909.88 |
| 81430 | Hearing loss panel, sequencing analysis | $1,267.50 |
| 81434 | Retinitis pigmentosa NGS panel | $466.37 |
| 81439 | Hypertrophic cardiomyopathy NGS panel, dilated & arrhythmogenic cardiomyopathy NGS panel | $456.22 |
| 81441 | Inherited bone marrow failure | $1,909.88 |
| 81442 | RASopathy NGS panel | $1,672.01 |
| 81443 | NGS Panel for the following conditions: Bardet-Biedl syndrome; Brugada syndrome; cholestasis; Coffin-Siris syndrome; comprehensive pulmonary; cone-rod dystrophy; congenital contractures; congenital stationary night blindness; early infantile epileptic encephalopathy; hereditary spastic paraplegia; Hermansky-Pudlak syndrome & pulmonary fibrosis; Kallmann syndrome & hypogonadotropic hypogonadism; leber congenital amaurosis; lysosomal storage disease; macular degeneration; mitochondrial depletion; neuromuscular disorders; non-immune hydrops; ocular albinism; optic atrophy & early glaucoma; overgrowth/macrocephaly; primary ciliary dyskinesia & cystic fibrosis; pulmonary arterial hypertension; Rett/Angelman syndrome; rhabdomyolysis & metabolic myopathies; syndromic autism; and vascular malformation | $1,909.88 |
| 81448 | Charcot-Marie-Tooth hereditary neuropathy NGS panel | $456.22 |
| 81451 | Hematolymphoid neoplasm or disorder (5-50 genes), RNA analysis | $592.43 |
| 81456 | Solid organ or hematolymphoid neoplasm or disorder (51 genes or greater), RNA analysis | $2,277.29 |
| 81470 | X-linked intellectual disability (XLID) NGS panel | $712.92 |
| 81479 | NGS Panel for the following conditions: central hypoventilation syndrome; Cornelia de Lange syndrome; craniosynostosis; dyskeratosis congenita; maturity-onset diabetes of the young; mitochondrial DNA variant; neuronal ceroid lipofuscinoses; periodic fever; peroxisomal biogenesis disorders; skeletal dysplasia; surfactant dysfunction & respiratory distress in premature infants; tuberous sclerosis complex; AlloSure heart; and AlloSure kidney | $890.08 |
South Carolina's Medicaid managed care organizations (MCOs) are responsible for the authorizations, coverage and reimbursement related to the services described in this bulletin for members enrolled in an MCO.
Providers should direct questions related to this bulletin to the Provider Service Center (PSC). PSC representatives can be reached at (888) 289-0709 from 7:30 a.m.-5 p.m. Monday-Thursday and 8:30 a.m.-5 p.m. Friday. Providers can also submit an online inquiry at https://www.scdhhs.gov/providers/contact-provider-representative.