MedicaidCoverageMedium impact
Pharmacogenomics Testing - MEDICAID - VIRGINIA (Revised)
Humana·VA · Psychiatry, Cardiology, Oncology +4 more·Medicaid
Effective date
Jul 22, 2026
We identified it
Jul 21, 2026
Summary
Humana Medicaid (Virginia) has revised its pharmacogenomics testing coverage policy effective 07/22/2026. The policy now covers molecular pathology testing (CPT 81479) for pharmacogenomics analysis when patients are being treated with or considered for medications with known FDA-labeled or CPIC guideline level A/B gene-drug interactions. A specific list of 17 branded pharmacogenomics tests are explicitly non-covered due to insufficient evidence.
Action Required
Before 07/22/2026: Billing team must update claim submission rules in billing software to DENY claims for the 17 specifically listed non-covered pharmacogenomics tests (codes 0031U, 0032U, 0258U, 0286U, 0328U, 0332U, 0348U, 0349U, 0350U, 0434U, 0437U, 0438U, 0460U, 0461U, 81283, 81328, 81535, 81536). Configure system to ALLOW CPT 81479 (unlisted molecular pathology) ONLY when accompanied by documentation of FDA-labeled or CPIC guideline level A/B gene-drug interaction. Providers must document the specific drug-gene interaction and guideline source on all pharmacogenomics test orders. Educate ordering providers on coverage criteria. Implement system edits to flag claims lacking interaction documentation for prior review. Non-covered test codes will be denied; CPT 81479 without proper documentation will be denied. NOTE: For members under age 21, all requests require medical necessity review per EPSDT requirements.