MedicaidCoverageMedium impact
Pharmacogenomics Testing - MEDICAID - MICHIGAN (New)
Humana·MI · Internal Medicine, Family Medicine, Cardiology +3 more·Medicaid
Effective date
Jul 22, 2026
We identified it
Jul 17, 2026
Summary
Humana Michigan Medicaid now covers pharmacogenomics testing (CPT 81479) for patients on medications with known gene-drug interactions per FDA labeling or CPIC guidelines (level A or B). However, ChemoFx Assay (CPT 81535/81536) and SLCO1B1 genotype testing (CPT 81328) are explicitly NOT covered due to insufficient evidence. Billing teams must verify drug-gene interaction documentation before submitting claims and deny or reject claims for the two excluded test codes.
Action Required
By July 22, 2026: (1) Billing team must update claim submission rules in billing software to flag CPT 81479 (pharmacogenomics testing) as COVERED ONLY when supporting documentation shows the patient is being treated with or considered for treatment with a medication that has a known gene-drug interaction per FDA labeling or CPIC guideline level A or B. (2) Configure system to DENY or auto-reject any claims submitted with CPT 81328, 81535, or 81536 — these codes are NOT covered under this Medicaid plan. (3) Update prior authorization or medical necessity templates to require providers to reference the specific FDA label or CPIC guideline (level A or B) supporting the testing request. (4) For members under age 21, ensure all pharmacogenomics requests are reviewed for medical necessity per EPSDT requirements. (5) Communicate coding restrictions to providers and clinical staff to prevent claim denials. Failure to implement these controls will result in claim rejections and may create compliance issues with Humana.