IHCP Revises Reimbursement Guidelines for BRCA Genetic Testing Services

The Indiana Health Coverage Programs (IHCP) reimburses for genetic testing for breast and ovarian cancer (BRCA1 and BRCA2) when medically necessary. These genetic testing procedure codes are manually priced and reimbursed at 90% of billed charges.

Consistent with IHCP billing guidelines, IHCP reimbursement for BRCA1 and BRCA2 genetic testing is limited to once per member per lifetime. To maintain consistency with other bundled laboratory codes, the IHCP considers certain aspects of these genetic tests to be components of more comprehensive tests. Accordingly, effective April 19, 2019, the IHCP will not reimburse for certain additional tests if a claim for BRCA1 and BRCA2 testing has previously paid, as indicated in Table 2. Claims for additional nonpayable genetic testing procedure codes (fourth column in Table 2) will deny with explanation of benefits (EOB) 6276 – Breast cancer analysis (BRCA1 & BRCA2) is not payable when a breast cancer analysis code has already been paid.