MedicaidCoverageMedium impact
Pharmacogenomics Testing - MEDICAID - SOUTH CAROLINA (Revised)
Humana·SC · Oncology, OB-GYN, Genetics +3 more·Medicaid
Effective date
Jul 22, 2026
We identified it
Jul 17, 2026
Summary
Humana Medicaid in South Carolina updated its pharmacogenomics testing coverage policy, effective July 22, 2026. The policy now covers ChemoFx Assay (CPT 81535/81536) for gynecologic cancers meeting specific clinical criteria, and molecular pathology testing (CPT 81479) for patients on medications with FDA-labeled or CPIC Level A/B gene-drug interactions. For members under 21, all requests require medical necessity review under EPSDT requirements.
Action Required
By July 22, 2026: Billing team must update billing system to recognize coverage for CPT 81479, 81535, and 81536 under South Carolina Medicaid. For ChemoFx Assay claims (81535/81536): Ensure providers document one of the five required gynecologic cancer indications (rare cancer with no established guidelines, initial biopsy/surgery, recurrent cancer, treatment-refractory, or unable to tolerate recommended treatment) before billing. For molecular pathology testing (CPT 81479): Verify the medication has FDA labeling or CPIC guideline Level A or B gene-drug interaction and include supporting documentation with claims. For members under age 21: Route all requests through medical necessity review per EPSDT requirements before processing. Update encounter forms and prior authorization templates to capture these requirements. Failure to document clinical criteria will result in claim denials.