Pharmacogenomics Testing

Pharmacogenomic testing is covered when a treating clinician documents that a patient needs a medication with known gene–drug interactions and the test results would directly affect drug selection or dosing, and when the test or its actionable components meet evidence standards (CPIC level A/B or FDA pharmacogenomic listings). Germline testing is limited to once per lifetime per beneficiary, duplicate germline testing or tests lacking established validity/utility are not covered, and the ordering provider must be the licensed treating clinician responsible for pharmacologic management. Coverage is subject to documentation requirements, coding rules, CMS payment policies, and post-payment audit.

"Pharmacogenetic testing is covered when the patient has a condition for which clinical evaluation has determined a need for a medication that has known gene–drug interaction(s) and the test results..."