MedicaidCoverageMedium impact
New Genetic Testing Benefits for Texas Medicaid Effective May 1, 2026
Texas Medicaid·TX · Oncology, Cardiology, Gastroenterology +2 more·General
Effective date
May 1, 2026
We identified it
Mar 25, 2026
Summary
Texas Medicaid is adding new genetic testing benefits effective May 1, 2026, including whole exome sequencing, FoundationOne cancer testing, transplant rejection monitoring, ClonoSEQ testing for blood cancers, enhanced liver fibrosis testing, and breast cancer index testing. All these new tests require prior authorization and have specific medical necessity criteria and frequency limitations.
Action Required
By May 1, 2026: Billing team must update system to require prior authorization for all new genetic testing codes (81415, 81416, 81417, 0037U, 0239U, 81595, 0493U, 0540U, 0364U, 81517, 81518). Update encounter forms with lifetime limits and age restrictions for each test. Train providers on medical necessity criteria and frequency limitations. Add required diagnosis codes for ClonoSEQ, enhanced liver fibrosis, and breast cancer index testing to billing system edits.