Physician Services Provider Manual Updates

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.

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.