Pharmacogenomics Testing

Medicare covers pharmacogenomic testing when a patient requires a medication with a known gene–drug interaction and the test is actionable per CPIC level A/B or listed in FDA pharmacogenomic/pharmacogenetic tables, such that results would directly change drug selection or dosing. Germline testing is limited to once per lifetime and duplicate testing of the same germline content is not covered; the ordering provider must be the treating clinician qualified to diagnose and prescribe and documentation must demonstrate medical necessity and evidence of actionability.

"Pharmacogenomic testing is reasonable and necessary when the patient requires a medication for which a known gene–drug interaction exists and the test result would directly impact drug management."

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