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Physician Services Provider Manual Updates


Effective for dates of service on or after March 1, 2024, the South Carolina Department of Health and Human Services will reimburse for the following laboratory services:

  • Oncotype DX® Breast Cancer Assay
  • Neuropharmagen Genomic Test

Updated policy language on the coverage of both of these laboratory tests will be available in the Physicians Services provider manual by March 1, 2024. The Community Mental Health Services provider manual will also include updated policy language on the coverage of the Neuropharmagen Genomic Test. Providers must utilize the following procedure codes, criteria and limitations when billing for these tests.

Procedure CodeDescriptionEligible MembersBenefit Criteria and LimitationsFee
81519Oncology (Breast), MRNA, Gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence score.Adults enrolled in full-benefit Medicaid coverage. This includes members who are enrolled in the breast and cervical cancer program.

One test per lifetime is covered. Medicaid members must have the following findings and diagnosis:

  • recently been diagnosed with stage I, stage II or stage III invasive breast cancer;
  • the cancer is estrogen receptor-positive;
  • the cancer is HER2-negative; and,
  • the cancer is lymph node-positive or lymph node-negative.

No prior authorization is required. Providers must file claims with primary diagnosis of the conditions listed above.

81418Drug metabolism (e.g., pharmacogenomics) genomic sequence analysis panel, must include testing of at least six genes, including CYP2C19, CYP2D6 and CYP2D6 duplication/deletion analysis.Medicaid members enrolled in full-benefit Medicaid coverage.

Prior authorization must be obtained for this genomic test.

Prior authorization requests must meet the following criteria:

  1. The test must be ordered by a board-certified psychiatrist or by a psychiatrist extender (psychiatric physician assistant or psychiatric nurse practitioner) under the supervision of a board-certified psychiatrist; and,
  2. The Medicaid member must have one of the following mental health conditions: general anxiety disorder, major depressive disorder, obsessive compulsive disorder, bipolar or schizophrenia; and,
  3. The Medicaid member must meet at least one of the following:
    1. The Medicaid member has experienced a trial and failure of two previous psychoactive drugs for the mental health condition being treated. OR
    2. The Medicaid member is currently taking more than two medications to treat the mental health condition.

South Carolina’s Healthy Connections Medicaid managed care organizations (MCOs) are responsible for the coverage and reimbursement of services described in this bulletin for members enrolled in an MCO.

Providers should direct any 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

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

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