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DEPARTMENT OF HEALTH AND HUMAN SERVICES 
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OFFICE OF INSPECTOR GENERAL 
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.... 	 WASHlNGTON, DC  2020]
JUN  t 2 2012 
TO: 	 Marilyn Tavenner 
Acting Admini strator 
Centers for Medicare & Medicaid Services 
FROM:  Stuart Wright 
Deputy Inspector General 
for Evaluation and Inspections 
SUBJECT: 	 Memorandum Report:  Coverage and Payment for Genetic Laboratory 
Tests, OEI-07-11-000 11 
This memorandum report provides the results of surveys sent to State Medicaid and 
Federal Employee Health Benefit (FEHB) programs and interviews with Veterans Health 
Administration (VHA) staff regarding coverage and payment for genetic laboratory tests. 
Centers for Medicare & Medicaid Services (CMS) officials requested this infonnation at 
the start of our study entitled Payments for Laboratory Tests: Comparing Medicare, 
State Medicaid, and Federal Employees Health Benefits Programs (OEI-07-11-00010). 
This infonnation is provided to assist CMS in its efforts to establish payment rates for 
genetic tests.  CMS has scheduled its annual laboratory public meeting for July 16,2012. 
At this meeting, 101 new genetic test codes for which no Medicare payment rates exist 
will be discussed. 
SUMMARY 
The Office of Inspector General (OIG) is currently conducting an evaluation entitled 
Paymentsfor Laboratory Tests:  Comparing Medicare, State Medicaid, and Federal 
Employees Health Benefits Programs (OEI-07-11-00010).  The objectives of that 
evaluation are to determine (I) how the methods for establishing Medicare laboratory test 
payment rates vary from State Medicaid and FEHB programs, and (2) the extent to which 
2011 Medicare payment rates for 20 high-volume and/or high-expenditure laboratory 
tests vary from State Medicaid and FEHB plans.  During a meeting on June 29, 2011, 
eMS officials informed us that, in addition to high-volume and high-expenditure 
laboratory tests, a collection of pricing data for genetic tests from other health care 
insurers would assist CMS in establishing payment rates for the 101 new genetic test 
codes in 2012. 
OEI-07-11-00011  Coverage and Payment for Genetic Laboratory Tests  Page 2  Marilyn Tavenner 
 
To answer the objectives of the earlier evaluation, we surveyed State Medicaid and 
FEHB plan staff to determine payment rates for each State and FEHB plan and to 
determine how their laboratory test payment rates were established.  To respond to CMS 
officials requests for similar information for genetic tests, we (1) surveyed State 
Medicaid and FEHB plan staff and interviewed VHA staff about their coverage policy 
and establishment of payment rates, and (2) obtained 2011 payment rates for selected 
genetic tests by name and by Common Procedural Terminology (CPT) code from each of 
the health care insurers we surveyed.  The payment rate information for genetic tests by 
CPT code is important because these codes are the basis underlying 101 new genetic test 
CPT codes. We are providing the results of the surveys and interviews in this 
memorandum for CMSs use in informing Medicare coverage and payment policies for 
genetic tests. 
 
BACKGROUND 
 
Clinical diagnostic laboratory tests (lab tests) are performed on specimens taken from the 
human body.  Lab tests provide information integral to preventing, diagnosing, and 
treating disease. Most lab tests are performed in hospitals, physicians offices, or 
independent laboratories. Genetic testing is the use of a lab test to look for genetic 
variations associated with a disease.1  Genetic tests can be used to predict, prevent, and  
inform the treatment of diseases.   
 
As with any new medical technology, genetic tests face challenges as they are integrated 
into the health care system, such as health care insurers decisions to provide coverage 
and establish payment rates for these services.  Although genetic testing has been 
performed for more than 20 years, these decisions are still evolving. 
 
Medicare Coverage of Genetic Tests  
The Social Security Act provides that no Medicare payment may be made for expenses 
incurred for items or services that are not reasonable and necessary for the diagnosis or 
treatment of illness or injury or to improve the functioning of a malformed body 
member.2  Consistent with this, Medicare does not pay for preventive screening tests 
except for those specifically authorized by statute (e.g., prostate-specific antigen test).  
Since CMS considers predictive tests to be screening tests, genetic tests for this purpose 
are not covered by Medicare. However, genetic tests used to diagnose or determine 
treatment in the presence of signs and symptoms of disease can be covered by Medicare.3   
A common use of genetic tests in the Medicare population is to assist in determining 
                                                 
1 
 National Human Genome Research Institute, National Institutes of Health.  Accessed at 

http://www.genome.gov on January 25, 2012. 
 
2 
 Social Security Act  1862(a)(1)(A). 
 
3 
 Secretarys Advisory Committee on Genetics, Health, and Society,  Coverage and Reimbursement of Genetic 
 
Tests and Services, February 2006, p. 30.  Accessed at http://oba.od.nih.gov/oba/sacghs/reports/CR_report.pdf on 

January 25, 2012. 
 
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 3  Marilyn Tavenner 
 
cancer treatment.  Genetic tests can be used to predict optimal chemotherapy regimens 
and avoid exposing patients to ineffective or overly toxic regimens.4  
 
Medicare uses a combination of national and local coverage determinations for making 
coverage decisions for genetic tests. National coverage determinations (NCD) are made 
at the Federal level and apply to all Medicare beneficiaries and Medicare administrative 
contractors (MAC). Currently, only two NCDs related to genetic tests have been 
established: (1) testing to predict patient responsiveness to the drug warfarin sodium, and 
(2) cytogenetic studies.5  MACs make local coverage determinations (LCD), which apply 
only to beneficiaries in the contractors jurisdiction.  Of the nearly 9,000 LCDs, only 
11 are related to genetic tests. For example, one MAC covers BRCA1 and BRCA2 
genetic testing for beneficiaries who meet certain criteria.6  
 
Medicare Payment for Genetic Tests  
The Clinical Laboratory Fee Schedule. The Deficit Reduction Act of 1984 (DRA) 
mandated that payment rates be established for lab tests on a regional, statewide, or 
carrier basis.7  The DRA also mandated that the Consumer Price Index for All Urban 
Consumers be used annually to adjust rates for inflation.  Beginning July 1, 1984, each 
carrier (i.e., Medicare Part B claims payment contractor) established its own payment 
rates based on the prevailing charges for lab tests in its locality.  These payment rates are 
collectively known as the Clinical Laboratory Fee Schedule (CLFS).   
  
CMS publishes an updated CLFS at least annually containing payment rates based on the 
57 jurisdictions of the former Medicare Part B claims payment carriers.  Although 
15 MACs have largely replaced the Medicare Part B claims payment carriers, MACs 
continue to administer the same payment policies created by the 57 carriers.  The 
2011 CLFS contains each carriers rate for 1,140 unique lab tests identified by CPT code, 
including some genetic tests.8, 9  
 
Annual Laboratory Meeting.   In accordance with section 1833(h)(8)(B) of the Social 
Security Act, CMS conducts an annual public meeting on payment rate recommendations 
for new lab test codes developed by the AMAs CPT Editorial Panel.  The meeting is 
intended to provide input on the nature of the new test codes and receive 
recommendations concerning the determination of payment rates.  In 2011, CMS 
                                                 
4 
 National Human Genome Research Institute, National Institutes of Health.  Accessed at 

http://www.genome.gov on January 25, 2012. 
 
5 
 CMS,  Medicare National Coverage Determinations Manual [Internet-Only  Manual], Pub.100-03, ch. 1, 

 90.1 and 190.3. Accessed at  http://www.cms.gov/Manuals/IOM/list.asp on January 25, 2012. 
 
6 
 Noridian Administrative Services, LCD ID Number L24308.  Accessed at http://www.cms.gov/medicare-
coverage-database/license/ on April 25, 2012. 

7 
 Deficit Reduction Act of 1984, P.L. 98-369,  2303(d), Social Security Act,  1833(h). 
 
8 
 CPT, a numeric coding system  maintained by  the American Medical Association (AMA), is a uniform coding 

system  consisting of descriptive terms and identifying codes that are used primarily to identify medical services 

and procedures furnished by physicians and other health care professionals.  CPTs make up one part of the 

Healthcare Common Procedure Coding System (HCPCS) code set. 

9 
 CMS, 2011 Clinical Laboratory Fee Schedule.  Accessed at https://www.cms.gov/ClinicalLabFeeSched on 

January 13, 2012. 
 
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 4  Marilyn Tavenner 
 
followed the public meeting with an information session on 101 new CPT codes for 
genetic tests that CMS plans to assign payment rates to in 2012.  The 2012 meeting is 
scheduled to be held on July 16.  
 
Payment Methods for Genetic Tests  
In 1992, AMA added a new section of CPT codes for genetic tests.  These codes focused 
on the laboratory procedure(s) used for a test rather than the substance or chemical 
analyzed. This coding system was developed to accommodate rapidly developing 
technologies. However, as stated in a pathology journal article, some health insurers 
expressed concern with this method because it led to a lack of standardization and a lack 
of specificity as to the test performed, which is discussed in greater detail below.10    
 
Stacking. Until 2012, Medicare did not use single CPT codes for genetic tests as it does 
for other lab tests (e.g., 81003-urinalysis automated without microscopy, 
85610-prothrombin time).  For nearly a decade, Medicare contractors, as well as other 
health care insurers, have used a reimbursement method referred to as stacking.  
Stacking is the use of multiple generic molecular diagnostic CPT codes (8389083914) to 
form the basis of reimbursement for a single genetic test.11  Payment rates for many of 
these individual CPT codes are listed on the CLFS.  Different laboratories may use 
differing procedures to perform the same lab test; therefore, they use differing quantities 
of CPT codes to file claims for the tests.  As shown in Table 1, a cystic fibrosis profile at 
one laboratory might be coded with a total of 29 units of 5 different CPT codes, while the 
same test from another laboratory might be coded with a total of 89 units of 6 different 
CPT codes.12   
   
                                                 
10 
 Anne Paxton, Molecular CPT Codes Topple Old Stacking Codes, CAP Today, April 2011.  Accessed at 
http://www.cap.org on January  13, 2012.  
11 
 Ibid.  
12 
 L. Joan Logue, Genetic Testing Coverage and Reimbursement:  A Providers Dilemma, Clinical Leadership 
& Management Review, November/December 2003, pp. 346350.   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 5  Marilyn Tavenner 
 
Table 1: Example of a Cystic Fibrosis Profile Offered by Two Laboratories  
 
Lab A Cystic Fibrosis 32 Mutations  
Code   Number of Units  Medicare CLFS Rate 
83890  1  $5.60 
83894  1  $5.60 
83896  25  $140.00 
83901  1  $23.42 
83912  1  $5.60
 Total  29  $180.22 
Lab B Cystic Fibrosis 32 Mutations  
Code   Number of Units  Medicare CLFS Rate 
83890  1  $5.60 
83892  1  $5.60 
83894  1  $5.60 
83896  84  $470.40 
83901  1  $23.42 
83912  1  $5.60
 Total  89  $516.22 
Note: The source of this example erroneously listed the Medicare CLFS rate as $54.60 for 

83912 for Lab B.
  
Source: L. Joan Logue, Genetic Testing Coverage and Reimbursement:  A Providers
  
Dilemma, Clinical Leadership & Management Review, November/December 2003, 

pp. 346350.
  
 
Medicare rules do not address the quantity or configuration of stacking codes for genetic 
tests. The lack of standardization results in wide variation in payment amounts for the 
same genetic test.  Another shortcoming of this reimbursement method is that it does not 
provide specificity to the payer as to what was tested because the same set of codes is 
used in a variety of genetic test types. 
 
Effective January 1, 2012, CMS instructed MACs to include in claims for genetic tests 
1 of the 101 new single CPT codes representing a genetic test as well as the underlying 
stacked codes.13  The new, single CPT codes do not yet have a payment amount assigned 
to them.  For now, claims will be paid according to the payment rates assigned to the 
underlying stacked codes. This new claim payment procedure may provide more 
information to CMS on the quantities of stacked codes underlying a single genetic test 
and the quantities and types of genetic tests provided to Medicare beneficiaries.  
However, it does not resolve the issue of variation in payment amounts. 
 
S Codes. Although most State Medicaid program and commercial health insurers 
(e.g., FEHB plans) use the stacking method of reimbursement, some alternatively use 
Healthcare Common Procedure Coding System (HCPCS) S codes.  S codes are 
assigned by the HCPCS Workgroup at the request of commercial insurers.  They are not 
reportable to Medicare. In contrast to stacking, a single S code captures all of the 
                                                 
13 
 CMS, Recurring Update Notification, Pub. No. 100-04, Transmittal 2365, Change Request 7654, dated 
December 9, 2011.  
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 6  Marilyn Tavenner 
 
components of the genetic test.  One example of an S code is S3818-complete gene 
sequence analysis of the BRCA1 gene.14  
 
Medicares Role in Establishing the Payment Rates of Other Health Care Insurers  
As the largest health insurer in the United States, Medicare has great influence on the  
actions of other health care insurers.  In fact, section 1903(i)(7) of the Social Security Act 
prohibits State Medicaid program payments for lab tests that exceed the Medicare 
payment amount.  In addition, private health insurance plans closely monitor Medicares 
coverage and reimbursement decisions.15  Therefore, it is important that CMS accurately 
formulate the reimbursement rates for genetic tests. 
 
VHA 
Unlike other Federal health insurance programs (e.g., Medicare), VHA operates its own 
medical centers and community-based outpatient clinics and permits more than 
53,000 independent licensed health care practitioners to work within those facilities.  
VHA is the largest integrated health care system in the United States, providing health 
care to approximately 8.3 million veterans.16  In 2006, the Department of Veterans 
Affairs launched the Genomic Medicine Program.  The goals of the program are:  (1) to 
examine the potential of emerging genomic technologies, (2) to optimize medical care for 
veterans, and (3) to enhance the development of tests and treatments for relevant 
diseases. 
 
METHODOLOGY 
 
Surveys 
From August through October 2011, we conducted an electronic survey of 50 State 
Medicaid programs and 3 FEHB plans that pay for lab tests on a fee-for-service basis.17   
We asked questions about their coverage policy for genetic laboratory tests; the methods 
established for payment of claims for genetic laboratory tests; and the payment rates in 
effect for the period January 1 through March 31, 2011, for 16 genetic tests by CPT 
stacking code and 16 selected genetic tests by name.  The 16 genetic tests by stacking 
codes were selected because they are included in the set of stacking codes underlying the 
101 new single genetic test codes. Appendix A contains lists of tests reviewed.   
 
We received completed surveys from all 50 State Medicaid programs and 3 FEHB plans.  
The three fee-for-service FEHB plans provide coverage to 90 percent of fee-for-service 
enrollees in the FEHB program.  Each of these national plans provides services through 
local plans and networks.  Within a single national plan, local plans and networks may 
                                                 
14 
 AMA, HCPCS Level II Professional Edition, 2011, p. 313. 

15 
 Secretarys Advisory Committee on Genetics, Health, and Society,  Coverage and Reimbursement of Genetic 
 
Tests and Services, February 2006, p. 25.  Accessed at http://oba.od.nih.gov/oba/sacghs/reports/CR_report.pdf on 

January 25, 2012. 

16 
 Accessed at http://www.va.gov/health/aboutVHA.asp  on March 20, 2012.
  
17 
 Staff from the Tennessee Medicaid program  stated that 100 percent of recipients are enrolled in managed care 

plans; therefore, Tennessee does not pay for any lab tests on a fee-for-service basis.  We did not include the 

Tennessee Medicaid program in our data collection.  We included the District of Columbia, for a total of 50 State 

Medicaid programs. 
 
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 7  Marilyn Tavenner 
 
have differing coverage policies and payment rates.  While FEHB plans provided 
payment rates representing all of their local plans and networks, they did not provide 
coverage policy and payment methods for each individual plan or network.  In total, we 
received surveys from 29 of 58 FEHB local plans and/or networks. 
 
Structured Interviews  
We conducted structured interviews with both national and local VHA staff.  We asked 
questions regarding coverage policy and payment for genetic tests.  We accessed VHA 
lab test payment rates on publicly available Web sites.  As previously stated, unlike 
Medicare, Medicaid, and FEHB, VHA operates its own medical centers and privileges 
and credentials its own providers to serve its members.  Therefore, we used a different  
data collection method with VHA than with the other health care insurers. 
 
Standards  
This study was conducted in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
 
RESULTS  
 
Below, we present information provided to us through surveys and interviews in the areas 
of coverage policies, payment methods, and payment rates. 
 
Coverage Policies for Genetic Tests  
We asked officials from each State Medicaid program, each FEHB plan, and VHA to  
describe their organizations coverage policy for genetic tests. 
  
State Medicaid Programs. Officials from all but one State Medicaid program described 
some level of coverage for genetic tests.  Officials from New Mexico stated that genetic 
tests are generally not covered.  Officials from 17 States stated that although genetic tests 
are covered, their States have no specific policy addressing them.  Officials from the 
remainder of States described a variety of factors that influenced coverage decisions, 
including performing genetic tests for the purpose of either diagnosis of a disease or 
treatment (nine States), requiring prior authorization for either all or certain types of 
genetic tests (eight States), and considering coverage on a case-by-case basis (six States).  
The Alabama Medicaid program volunteered that it is working with a consultant to 
develop a coverage policy. 
 
FEHB Plans.  Officials from each of the three national FEHB plans described some level 
of coverage for genetic tests. At the time of our data collection, officials from one 
national plan reported that, in the past, coverage for specific genetic tests was evaluated 
for medical necessity on an individual basis.  However, the plan had recently experienced 
increased demand for genetic tests, so plan officials were working on a more robust 
policy. Of the 29 local and network plans, 4 reported that coverage policies are 
test-specific and 3 required preauthorization for genetic tests. 
 
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 8  Marilyn Tavenner 
 
VHA.  VHA places a strong emphasis on medical coverage decisionmaking by a patients 
clinician(s). According to regulations found at 38 CFR 17.38(b), care referred to in the 
medical benefits package18 will be provided to individuals only if it is determined by 
appropriate health care professionals that the care is needed to promote, preserve, or 
restore the health of the individual and is in accord with generally accepted standards of 
medical practice.  VHA officials reported to us that tests used to make a primary 
diagnosis or to modify treatment are easily justified.  A medical centers pathologist 
serves as a gatekeeper to evaluate the test ordered by a clinician against clinical 
requirements.     
 
Payment Methods 
State Medicaid Programs. Thirty-nine State Medicaid programs reported that they paid 
for genetic tests using only the stacking method.  Two States reported that they paid for 
genetic tests only by test name (e.g., by S code).  Eight States reported using a 
combination of these methods.  One State reported that it did not cover genetic tests, and 
therefore did not report a payment method. 
   
Of the 47 State Medicaid programs that reported paying for genetic tests using the 
stacking method, only Iowa determined a maximum quantity and combination of stacked 
codes that it would reimburse for a given test.  Iowa reported the maximum number and 
combination of stacked codes for 6 of the 16 genetic tests on our survey.  These 
combinations are shown in Appendix B.  Minnesota reported the set of stacked codes it 
allowed for certain tests, but did not specify  a maximum quantity for each of these codes.  
These combinations are shown in Appendix C.  
 
FEHB Plans. One national FEHB plan reported that it did not approve many genetic 
tests. This plan noted that some tests do not have CPT codes associated with them; the 
plan prices these tests based on available fee data.  The plan is in the process of 
developing a pricing strategy for an expected increase in usage of genetic tests.  Another 
national FEHB plan responded that payment for a genetic test is based on claim  
information and contractual rates.  The remaining national FEHB plan noted that 
responses varied among the local plans, with some plans using stacked CPT codes and 
some plans paying by test name.  
 
VHA. Some VHA medical center laboratories can perform certain genetic tests onsite, 
but the majority of genetic test specimens are sent to reference laboratories for 
processing. VHA has national contracts with four reference laboratories.  The contracts 
contain a list price for each lab test offered.  In addition, VHAs regionally based service 
networks, or individual medical centers within those networks, may negotiate prices 
lower than contract list prices based on volume.  Because genetic test volume has been 
low, staff from one medical center reported that in most cases, the volume has not been 
large enough to justify negotiating prices lower than list prices. 
 
   
                                                 
18 
 The definition of medical benefits package can be found in 38 CFR  17.38.  It includes services such as  
outpatient, hospital, and extended care.  
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 9  Marilyn Tavenner 
 
Payment Rates  
We asked officials from each State Medicaid program and FEHB plan to provide us with 
the payment rates in effect for January 1 through March 31, 2011, for 16 genetic tests by 
CPT stacking code and 16 selected genetic tests by name.  State Medicaid programs 
provided their fee schedules for lab tests, representing the maximum payment rate 
allowed for each test. (For actual claims, providers could have billed for less than the fee 
schedule amount.) FEHB plans provided us with median claim payment amounts for lab 
tests performed during the period of our review.   
 
State Medicaid Programs. Appendix D compares State Medicaid program fee schedule 
rates for 16 genetic tests by CPT stacking codes with Medicare CLFS payment rates.  
Eight State Medicaid programs provided payment rates by test name.  These prices are 
shown in Appendix E. We note great variation in test prices; for example, the payment 
rate for a BRCA1 gene analysis ranged from $1,000 in Pennsylvania to nearly $4,500 in 
Iowa. 
 
FEHB Plans. Appendix D compares FEHB plan median payment rates for 16 genetic 
tests by CPT stacking code with Medicare CLFS payment rates.  One national FEHB 
plan provided prices for genetic tests by name. These prices are shown in Appendix F. If 
the FEHB plan did not pay a lab test claim for a particular test, no price is listed.  Similar 
to State Medicaid programs, FEHB plans reported variation in tests prices.  For example, 
the AlloMap ranged from $2 to $3,658. Other tests had less price variation, such as the 
    
Pathwork Tissue of Origin, which ranged from $5 to $38.  One FEHB plan official noted 
that the variation in payment rates is likely due to low test volume and services provided 
by nonpreferred provider organizations. The plan is reviewing instances in which its 
payment rates are higher than other insurers. 
 
VHA. VHA has national contracts with four laboratories:  ARUP Laboratories, 
Laboratory Corporation of America, Quest Diagnostics Nichols Institute, and Sonora 
Quest Laboratories, LLC. Only one contractor lists prices by CPT code.  We have not 
included contract list prices in this memorandum because this information can be located 
on the General Services  Administration Web site.19    
 
CONCLUSION 
 
We have provided this information for CMSs use in setting Medicare coverage and 
payment policies for genetic tests.  Because State Medicaid programs and private health 
insurance plans closely monitor Medicares coverage and reimbursement decisions, 
CMSs formulation of reimbursement rates for genetic tests may be useful to them.  As  
one official from a State Medicaid program remarked, Additional guidance from CMS 
on genetic testing would be very helpful.  We have struggled with payment of such tests 
for the last couple of years. 
 
                                                 
19 
 General Services Administration, Medical Laboratory  Testing and Analysis Services, Schedule 621 II.  
Accessed at http://www.gsaelibrary.gsa.gov on February 24, 2012.  
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 10  Marilyn Tavenner 
 
This report is being issued directly in final form because it contains no recommendations.  
If you have comments or questions about this report, please provide them within 60 days.  
Please refer to report number OEI-07-11-00011 in all correspondence. 
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 11  Marilyn Tavenner 
 
APPENDIX A 
Genetic Tests Included in Review  
 
Genetic Tests by Current Procedural Terminology Stacking Code Included in Review  
Code  Description  
83890   Molecular diagnostics; molecular isolation or extraction, each nucleic acid type  
Molecular diagnostics; isolation or extraction of highly purified nucleic acid, 
83891  
each nucleic acid type  
83892   Molecular diagnostics; enzymatic digestion, each enzyme treatment  
Molecular diagnostics; separation by gel electrophoresis, each nucleic acid 
83894  
preparation  
83896   Molecular diagnostics; each nucleic acid probe 
83897   Molecular diagnostics; nucleic acid transfer, each nucleic acid preparation  
83898   Molecular diagnostics; amplification, target, each nucleic acid sequence 
Molecular diagnostics; amplification, target, multiplex, first two nucleic acid 
83900  
sequences 
Molecular diagnostics; amplification, target multiplex, each additional nucleic 
83901  
acid sequence beyond the first two 
83902   Molecular diagnostics; reverse transcription 
Molecular diagnostics; mutation identification by sequencing, single segment, 
83904  
each segment  
83907   Molecular diagnostics; lysis of cells prior to nucleic acid extraction  
Molecular diagnostics; separation and identification by high resolution 
83909  
technique 
83912   Molecular diagnostics; interpretation and report  
Mutation identification by enzymatic ligation or primer extension, single 
83914  
segment, each segment  
88271   Molecular cytogenetics; each DNA probe  
Source:  American  Medical Association, Current Procedural Terminology  2009 Standard Edition, pp. 276292. 
 
 
Genetic Tests by Name Included in Review 
AlloMap 

OncoTypeDX
  
PathFinderTG 

Pathwork Tissue of Origin
  
VeriStrat
  
ChemoFx 

Oncotech EDR 

MSH2 Gene Analysis 

MLH1 Gene Analysis
  
KRAS Gene Analysis 

HFE Gene Analysis 

F2 Gene Analysis 
 
CFTR Gene Analysis 
 
BRCA1 Gene Analysis 

BRCA2 Gene Analysis 

BCR/ABL1 Translocation Analysis 

   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 12  Marilyn Tavenner 
 
APPENDIX B  
 
Table B-1: Iowa Medicaid Program Quantities of Stacked Codes Allowed in Reimbursement for 
Selected Genetic Tests  
Current  Genetic Test  
Procedural  Pathwork  KRAS  BCR/ABL1 
F2 Gene 
Terminology   Tissue of  VeriStrat  ChemoFX   Gene  Translocation 
Analysis 
Code   Origin  Analysis  Analysis 
83890   1    1     
83891   1      1  1 
83892   1    3     
83893   1           
83894   1      1  1 
83896   1           
83897   1           
83898   1    1  2  9 
83900   1           
83901   1           
83902   1          1 
83903   1           
83904   1      2   
83905   1           
83906   1           
83907   1    1     
83908   1           
83909   1  1    2     
83912   1    1  1  1 
83913   1           
83914         4     
84999   1           
87230       1   
88104       1   
88230       1   
88233       1   
88235       1   
88237       1   
88239       1   
88305       1   
88313       1   
88358       1   
88381         1     
88384   1           
88385   1           
88386   1           
89050       1   
Source:  Office of  Inspector General analysis of  Iowa Medicaid program survey response, 2011. 
 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 13  Marilyn Tavenner 
 
APPENDIX C 
 
Table C-1: Minnesota Medicaid Program Stacked Codes Allowed in 
Reimbursement for Selected Genetic Tests  
Current  Genetic Test  
Procedural 
CFTR Gene   HFE Gene   MLH1 Gene  MSH2 Gene 
Terminology  
Analysis  Analysis  Analysis  Analysis 
Code  
83890   X  X 
83891   X  X  X 
83892   X  X  X 
83893   X       
83894   X       
83896   X       
83897   X       
83898   X  X  X  X 
83900   X       
83901   X       
83902   X       
83903   X       
83904   X  X  X 
83905   X       
83906   X       
83909      X  X 
83912     X  X  X 
Source:  Office of  Inspector General analysis of Minnesota Medicaid program survey response, 2011. 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 14  Marilyn Tavenner 
 
APPENDIX D 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit* Payment Rates for Selected Genetic Test Codes  
Current  State 
Procedural 
Insurer 
Terminology   AK  AL  AR  AZ  CA 
Code  
Medicare  $5.64   $5.55   $5.64   $5.64   $5.64  
Medicaid  $5.74   $5.55   $5.72   $5.45   $4.39  
83890   FEHB 1   N/A  $5.94   N/A  N/A  N/A 
FEHB 2   N/A  N/A  N/A  $107.50   $25.20  
FEHB 3   $5.00   $5.36   $6.72   $3.35   $4.86  
Medicare  $5.64   $5.55   $5.64   $5.64   $5.64  
Medicaid  $5.74   $4.00   $5.72   $5.45   $4.39  
83891   FEHB 1   N/A  $3.98   $6.45   $5.94   $5.94  
FEHB 2   $4.45   $6.19   $8.40   $5.88   $5.88  
FEHB 3   $31.00   $4.95   $4.89   $4.86   $4.86  
Medicare  $5.64   $5.55   $5.64   $5.64   $5.64  
Medicaid  $5.74   $5.55   $5.72   $5.45   $4.39  
83892   FEHB 1   N/A  N/A  $31.61   N/A  $5.94  
FEHB 2   $5.60   $15.10   $9.20   $6.19   $5.88  
FEHB 3   $79.11   $9.90   $7.46   $6.68   $9.90  
Medicare  $5.64   $5.55   $5.64   $5.64   $5.64  
Medicaid  $5.74   $5.00   $5.72   $5.45   $4.39  
83894   FEHB 1   N/A  N/A  $5.46   N/A  $5.94  
FEHB 2   N/A  $24.00   $19.00   $45.38   $11.31  
FEHB 3   $11.28   $12.44   $5.04   $5.09   $9.86  
Medicare  $5.64   $5.55   $5.64   $5.64   $5.64  
Medicaid  $5.74   $5.55   $5.72   $5.45   $4.39  
83896   FEHB 1   N/A  $5.49   $43.07   $5.46   $5.40  
FEHB 2   $5.60   $6.19   $28.00   $5.88   $5.88  
FEHB 3   $35.56   $9.90   $7.46   $13.15   $30.00  
Medicare  $5.64   $5.55   $5.64   $5.64   $5.64  
Medicaid  $5.74   $4.00   $5.72   $5.45   $4.39  
83897   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  $55.00   N/A  N/A 
FEHB 3   N/A  N/A  N/A  N/A  $6.26  
Medicare  $23.58   $9.52   $23.58   $23.58   $23.58  
Medicaid  $24.01   $9.52   $23.94   $22.81   $18.35  
83898   FEHB 1   N/A  $24.85   N/A  N/A  $23.53  
FEHB 2   $14.00   $36.00   $55.00   $35.01   $35.01  
FEHB 3   $30.00   $19.38   $20.69   $22.45   $35.16  
Medicare  $47.18   $19.03   $47.18   $47.18   $47.18  
Medicaid  N/A  $13.00   $48.40   $45.62   $37.10  
83900   FEHB 1   N/A  $79.65   $48.94   $49.69   $30.99  
FEHB 2   N/A  $26.18   $46.84   $38.00   $40.36  
FEHB 3   $116.68   $16.94   $40.90   $23.68   $40.68  
continued on next page 
Note:  N/A indicates  that no price was  reported  for the  test. 
*FEHB. 
 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 15  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   AK  AL  AR  AZ  CA 
Code  
Medicare  $23.58   $9.52   $23.58   $23.58   $23.58  
Medicaid  $24.01   $6.00   $23.94   $22.81   $18.35  
83901   FEHB 1   N/A  $16.68   $21.08   $6.39   $18.55  
FEHB 2   N/A  $7.32   $42.67   $15.93   $12.27  
FEHB 3   $156.26   $136.64   $204.33   $20.80   $159.97  
Medicare  $12.09   $5.55   $19.97   $19.97   $19.97  
Medicaid  $12.31   $4.00   $20.26   $19.31   $15.53  
83902   FEHB 1   N/A  N/A  $5.47   $5.47   $17.15  
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $31.00   $9.90   $8.79   $19.00   $9.90  
Medicare  $23.58   $9.52   $23.58   $23.58   $23.58  
Medicaid  $24.01   $7.00   $23.94   $22.81   $18.35  
83904   FEHB 1   N/A  N/A  $23.54   N/A  $23.54  
FEHB 2   $37.86   N/A  N/A  $35.01   $35.01  
FEHB 3   $47.16   $83.38   $56.73   $89.79   $141.00  
Medicare  $18.80   $18.80   $18.80   $18.80   $18.80  
Medicaid  $19.13   $13.00   $19.28   $18.17   $14.78  
83907   FEHB 1   N/A  $58.80   $58.80   N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $16.92   $16.21   $24.87   $17.88   $16.21  
Medicare  $23.58   $9.52   $23.58   $23.58   $23.58  
Medicaid  $24.01   $7.00   $24.20   $22.81   $18.55  
83909   FEHB 1   N/A  $6.13   $20.27   $14.03   $15.49  
FEHB 2   $13.00   $13.49   $23.42   $6.39   $13.49  
FEHB 3   $49.75   $9.69   $20.56   $14.59   $20.34  
Medicare  $5.64   $5.55   $5.64   $5.64   $5.64  
Medicaid  $5.74   $5.55   $5.72   $5.45   $4.39  
83912   FEHB 1   N/A  $4.43   $6.89   $5.46   $5.94  
FEHB 2   $4.23   $37.60   $19.20   $25.80   $5.88  
FEHB 3   $11.28   $4.95   $8.40   $5.66   $4.95  
Medicare  $23.58   $9.52   $23.58   $23.58   $23.58  
Medicaid  $24.01   $7.00   $24.20   $22.81   $18.55  
83914   FEHB 1   N/A  $39.97   $73.80   $3.20   $15.49  
FEHB 2   N/A  N/A  $21.99   $13.11   $15.51  
FEHB 3   $127.32   $103.78   $271.04   $50.58   $165.78  
Medicare  $30.14   $23.42   $30.14   $30.14   $30.14  
Medicaid  $30.68   $21.00   $30.59   $29.15   $23.44  
88271   FEHB 1   N/A  N/A  $30.66   N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $120.56   $100.00   $82.92   $92.32   $93.56  
continued on next page 
 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 16  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   CO  CT  DC  DE  FL 
Code  
Medicare  $5.64   $5.64   $5.64   $5.64   $3.59  
Medicaid  $4.97   $5.32   $3.00   $5.53   $2.00  
83890   FEHB 1   N/A  N/A  N/A  N/A  $8.97  
FEHB 2   $5.36   N/A  $4.76   N/A  $20.76  
FEHB 3   $2.54   $5.54   $5.00   $4.78   $4.00  
Medicare  $5.64   $5.64   $5.64   $5.64   $3.59  
Medicaid  $4.97   $5.32   $88.00   $5.53   $2.00  
83891   FEHB 1   $5.78   $5.78   $5.94   N/A  $5.78  
FEHB 2   $4.51   $5.06   $5.88   N/A  $5.88  
FEHB 3   $4.95   $3.44   $5.00   $7.62   $4.95  
Medicare  $5.64   $5.64   $5.64   $5.64   $3.59  
Medicaid  $4.97   $5.32   $3.00   $5.53   $2.00  
83892   FEHB 1   $5.60   $5.25   $5.94   N/A  $5.25  
FEHB 2   $5.20   $5.88   $6.19   $2.35   $6.04  
FEHB 3   $9.90   $6.88   $9.35   $9.28   $9.90  
Medicare  $5.64   $5.64   $5.64   $5.64   $3.59  
Medicaid  $4.97   $5.32   $3.00   $5.53   $2.00  
83894   FEHB 1   $5.94   N/A  $5.94   N/A  $5.94  
FEHB 2   $5.36   N/A  $4.76   $2.35   $24.00  
FEHB 3   $7.63   $7.25   $5.00   $10.00   $8.31  
Medicare  $5.64   $5.64   $5.64   $5.64   $3.59  
Medicaid  $4.97   $5.32   $3.00   $5.53   $2.49  
83896   FEHB 1   $5.25   $5.25   $5.70   N/A  $5.25  
FEHB 2   $4.09   $5.88   $5.32   N/A  $5.88  
FEHB 3   $9.90   $13.76   $15.00   $11.14   $9.90  
Medicare  $5.64   $5.64   $5.64   $5.64   $3.59  
Medicaid  $4.97   $5.32   $10.00   $5.53   $2.00  
83897   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $5.60   N/A  N/A  N/A  $8.31  
Medicare  $23.58   $23.58   $23.58   $23.58   $23.58  
Medicaid  $20.83   $22.25   $11.00   $23.11   $2.00  
83898   FEHB 1   $23.53   $22.65   $24.85   N/A  $24.85  
FEHB 2   $15.33   $24.02   $19.91   N/A  $35.01  
FEHB 3   $20.69   $42.20   $10.00   $27.28   $35.00  
Medicare  $47.18   $47.18   $47.18   $47.18   $47.18  
Medicaid  $44.31   $44.03   $24.36   $46.24   $32.79  
83900   FEHB 1   $34.42   $104.41   $30.99   N/A  $60.18  
FEHB 2   $25.16   N/A  $40.36   N/A  $23.98  
FEHB 3   $20.86   $28.81   $5.18   $39.99   $27.17  
continued on next page 
 
 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 17  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   CO  CT  DC  DE  FL 
Code  
Medicare  $23.58   $23.58   $23.58   $23.58   $23.58  
Medicaid  $20.83   $22.25   $10.00   $23.11   $16.00  
83901   FEHB 1   $16.68   N/A  $18.56   N/A  $22.32  
FEHB 2   $15.57   N/A  $19.91   N/A  $11.99  
FEHB 3   $144.84   $160.01   $70.00   $159.38   $160.11  
Medicare  $19.97   $19.97   $19.97   $19.97   $15.28  
Medicaid  $17.63   $18.84   $9.00   $19.57   $10.50  
83902   FEHB 1   $21.04   N/A  N/A  N/A  $16.86  
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $9.90   $27.70   $19.00   $31.00   $19.68  
Medicare  $23.58   $23.58   $23.58   $23.58   $23.58  
Medicaid  $20.83   $22.25   $32.00   $23.11   $16.00  
83904   FEHB 1   N/A  N/A  N/A  N/A  $20.98  
FEHB 2   $35.01   $13.02   N/A  N/A  $35.01  
FEHB 3   $93.68   $59.15   $54.42   $122.07   $89.79  
Medicare  $18.80   $18.80   $17.28   $18.80   $18.80  
Medicaid  $12.54   $17.54   $8.92   $18.42   $13.06  
83907   FEHB 1   $58.80   N/A  N/A  N/A  $15.87  
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $13.00   $33.63   $25.20   $25.05   $13.00  
Medicare  $23.58   $23.58   $23.58   $23.58   $23.58  
Medicaid  $15.74   $22.01   $12.18   $23.11   $16.39  
83909   FEHB 1   $18.75   $52.19   $24.85   N/A  $30.26  
FEHB 2   $22.40   $13.26   $14.83   N/A  $11.96  
FEHB 3   $10.35   $14.41   $2.59   $19.99   $13.58  
Medicare  $5.64   $5.64   $5.64   $5.64   $3.59  
Medicaid  $5.25   $2.66   $3.00   $5.53   $10.18  
83912   FEHB 1   $5.25   $5.25   $5.94   N/A  $5.94  
FEHB 2   $4.09   $4.85   $5.88   $2.35   $5.88  
FEHB 3   $4.95   $5.54   $5.00   $5.57   $4.95  
Medicare  $23.58   $23.58   $23.58   $23.58   $23.58  
Medicaid  $15.74   $22.01   $12.18   $23.11   $16.39  
83914   FEHB 1   $33.02   N/A  $15.49   N/A  $18.20  
FEHB 2   $11.86   $19.17   $19.17   N/A  $11.99  
FEHB 3   $287.90   $392.32   $82.88   $383.12   $394.19  
Medicare  $30.14   $30.14   $30.14   $30.14   $20.37  
Medicaid  $26.61   $28.43   $84.00   $29.54   $14.00  
88271   FEHB 1   $48.00   N/A  N/A  N/A  $31.75  
FEHB 2   N/A  N/A  $68.93   N/A  $76.00  
FEHB 3   $179.58   $232.56   $91.00   $23.39   $78.86  
continued on next page 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 18  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   GA  HI  IA  ID  IL 
Code  
Medicare  $5.55   $5.64   $5.64   $5.64   $5.64  
Medicaid  $4.96   $5.54   $5.36   $5.60   $5.25  
83890   FEHB 1   $7.35   N/A  $56.32   N/A  $7.64  
FEHB 2   $7.30   N/A  N/A  N/A  N/A 
FEHB 3   $4.34   N/A  $7.00   $6.66   $7.00  
Medicare  $5.55   $5.64   $5.64   $5.64   $5.64  
Medicaid  $4.96   $5.54   $5.36   $5.60   $5.25  
83891   FEHB 1   $5.94   N/A  N/A  $5.78   $2.92  
FEHB 2   $5.88   N/A  N/A  N/A  $7.81  
FEHB 3   $4.95   $7.42   $6.52   $4.45   $4.95  
Medicare  $5.55   $5.64   $5.64   $5.64   $5.64  
Medicaid  $4.96   $5.54   $5.36   $5.60   $5.05  
83892   FEHB 1   $5.46   N/A  N/A  N/A  N/A 
FEHB 2   $5.94   N/A  N/A  N/A  $7.00  
FEHB 3   $9.90   $15.20   $21.00   N/A  $9.90  
Medicare  $5.55   $5.64   $5.64   $5.64   $5.64  
Medicaid  $4.96   $5.54   $5.36   $5.60   $5.05  
83894   FEHB 1   $5.26   N/A  N/A  N/A  N/A 
FEHB 2   $14.94   N/A  N/A  N/A  $14.94  
FEHB 3   $5.46   $19.00   $12.00   $3.94   $5.85  
Medicare  $5.55   $5.64   $5.64   $5.64   $5.64  
Medicaid  $4.96   $5.54   $5.36   $5.60   $5.25  
83896   FEHB 1   $5.46   N/A  $45.07   N/A  $9.26  
FEHB 2   $5.88   N/A  N/A  N/A  $10.64  
FEHB 3   $9.90   $7.23   $14.00   $30.00   $9.90  
Medicare  $5.55   $5.64   $5.64   $5.64   $5.64  
Medicaid  $4.96   $5.54   $5.36   $5.60   $5.25  
83897   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $4.41   $7.23   N/A  N/A  $7.42  
Medicare  $5.40   $23.58   $23.58   $5.80   $23.58  
Medicaid  $4.83   $23.17   $22.40   $5.75   $21.90  
83898   FEHB 1   $24.19   N/A  $218.52   $22.66   $36.54  
FEHB 2   $35.01   N/A  N/A  N/A  $36.00  
FEHB 3   $10.00   $168.02   $34.00   $32.94   $20.34  
Medicare  $10.82   $47.18   $47.18   $11.58   $47.18  
Medicaid  $9.67   $28.10   $44.82   $11.50   $28.10  
83900   FEHB 1   $65.42   N/A  N/A  N/A  $44.85  
FEHB 2   $37.47   N/A  N/A  N/A  $32.47  
FEHB 3   $10.56   $60.52   $78.27   $47.78   $34.00  
continued on next page 
 
 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 19  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   GA  HI  IA  ID  IL 
Code  
Medicare  $5.40   $23.58   $23.58   $5.80   $23.58  
Medicaid  $4.83   $23.17   $22.40   $5.75   $21.90  
83901   FEHB 1   $24.85   N/A  N/A  N/A  $12.26  
FEHB 2   $15.00   N/A  N/A  N/A  $22.88  
FEHB 3   $73.92   $665.72   $5.22   $93.91   $221.00  
Medicare  $17.82   $19.97   $19.97   $5.80   $19.97  
Medicaid  $15.92   $19.61   $18.97   $5.75   $18.50  
83902   FEHB 1   $5.26   N/A  N/A  N/A  $40.80  
FEHB 2   $36.60   N/A  N/A  N/A  N/A 
FEHB 3   $19.00   N/A  $23.00   $14.01   $23.00  
Medicare  $5.40   $23.58   $23.58   $5.80   $23.58  
Medicaid  $4.83   $23.17   $22.40   $5.75   $21.90  
83904   FEHB 1   $35.98   N/A  N/A  N/A  N/A 
FEHB 2   $35.01   N/A  N/A  N/A  N/A 
FEHB 3   $32.07   $272.34   $90.00   $0.00   $371.01  
Medicare  $18.80   $18.80   $18.80   $18.80   $18.80  
Medicaid  $16.79   $13.06   $17.86   $18.66   $11.19  
83907   FEHB 1   $33.02   N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $17.88   N/A  $22.00   $13.12   $17.88  
Medicare  $5.40   $23.58   $23.58   $5.80   $23.58  
Medicaid  $4.83   $16.39   $22.40   $5.75   $14.05  
83909   FEHB 1   $30.27   N/A  N/A  $30.00   $102.33  
FEHB 2   $13.49   N/A  N/A  N/A  $12.26  
FEHB 3   $12.29   $40.75   $48.00   $345.60   $17.25  
Medicare  $5.55   $5.64   $5.64   $5.64   $5.64  
Medicaid  $4.96   $5.60   N/A  $5.60   $5.25  
83912   FEHB 1   $5.46   N/A  $54.95   $5.25   $9.26  
FEHB 2   $5.88   N/A  N/A  N/A  $10.69  
FEHB 3   $4.95   $8.40   $7.00   $5.36   $22.33  
Medicare  $5.40   $23.58   $23.58   $5.80   $23.58  
Medicaid  $4.83   $16.39   $22.40   $5.75   $14.05  
83914   FEHB 1   $24.85   N/A  N/A  $38.82   $6.14  
FEHB 2   $18.74   N/A  N/A  N/A  $12.69  
FEHB 3   $215.51   $394.19   $82.88   $229.04   $340.00  
Medicare  $30.14   $30.14   $30.14   $20.37   $20.37  
Medicaid  $26.94   $29.60   $28.63   $20.22   $18.90  
88271   FEHB 1   $30.00   N/A  N/A  N/A  N/A 
FEHB 2   $88.95   N/A  N/A  N/A  N/A 
FEHB 3   $86.04   N/A  $442.00   $51.98   $109.50  
continued on next page 
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 20  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   IN  KS*  KY  LA  MA 
Code  
Medicare  $5.64   $3.29/$5.64*   $5.55   $5.64   $5.64  
Medicaid  $5.54   $5.54   $5.55   $4.15   $4.18  
83890   FEHB 1   $8.77   N/A  N/A  N/A  $9.36  
FEHB 2   N/A  N/A  $5.65   $10.83   N/A 
FEHB 3   $7.18   $5.55   $4.55   $7.24   $6.26  
Medicare  $5.64   $3.29/$5.64*   $5.55   $5.64   $5.64  
Medicaid  $5.54   $5.54   $5.55   $4.56   $4.18  
83891   FEHB 1   $4.26   $6.01   $9.64   $5.04   $9.36  
FEHB 2   $5.06   N/A  $5.88   $5.88   $5.88  
FEHB 3   $3.51   $4.95   $2.92   $4.95   $6.26  
Medicare  $5.64   $3.29/$5.64*   $5.55   $5.64   $5.64  
Medicaid  $5.54   $5.54   $5.55   $4.15   $4.18  
83892   FEHB 1   N/A  $5.94   $5.25   $16.52   N/A 
FEHB 2   $14.94   N/A  $14.94   $7.05   $5.88  
FEHB 3   $7.90   $9.90   $10.66   $9.90   $6.26  
Medicare  $5.64   $3.29/$5.64*   $5.55   $5.64   $5.64  
Medicaid  $5.54   $5.54   $5.55   $4.15   $4.18  
83894   FEHB 1   N/A  $5.94   N/A  $28.00   N/A 
FEHB 2   $24.00   N/A  $24.00   $24.00   N/A 
FEHB 3   $7.63   $5.00   $16.53   $8.88   $16.20  
Medicare  $5.64   $3.29/$5.64*   $5.55   $5.64   $5.64  
Medicaid  $5.54   $5.54   $5.55   $4.15   $4.18  
83896   FEHB 1   $5.60   $5.46   $5.25   $16.52   $9.36  
FEHB 2   $5.88   N/A  $5.77   $5.88   $5.88  
FEHB 3   $23.69   $9.90   $19.52   $9.90   $12.52  
Medicare  $5.64   $3.29/ $5.64*   $5.55   $5.64   $5.64  
Medicaid  $5.54   $5.54   $5.55   $4.56   $4.18  
83897   FEHB 1   N/A  N/A  N/A  $23.80   N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   N/A  N/A  N/A  $15.52   $111.32  
Medicare  $23.58   $23.58   $23.58   $23.58   $6.14  
Medicaid  $23.17   $21.60   $23.58   $17.32   $4.55  
83898   FEHB 1   $23.42   $23.75   N/A  $21.08   $16.42  
FEHB 2   $35.01   N/A  $30.01   $35.51   N/A 
FEHB 3   $26.94   $43.89   $20.11   $20.34   $29.15  
Medicare  $47.18   $47.18   $47.18   $47.18   $12.29  
Medicaid  $46.84   $39.81   $47.18   $19.60   $9.11  
83900   FEHB 1   $63.24   $92.46   N/A  $106.02   N/A 
FEHB 2   $24.57   N/A  $24.57   $40.36   N/A 
FEHB 3   $29.37   $41.12   $31.77   $36.02   $46.50  
continued on next page 
* Four States (CA, KS, MO, and NY) are divided into multiple Medicare carrier jurisdictions.  Each jurisdiction may have a different price for   
some Current Procedural Terminology codes.  In jurisdictions where prices differ, differences are signified using / between each  
jurisdictions price.  
 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 21  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   IN  KS*  KY  LA  MA 
Code  
Medicare  $23.58   $23.58   $23.58   $23.58   $6.14  
Medicaid  $23.17   $5.54   $23.58   $19.04   $4.55  
83901   FEHB 1   $30.15   N/A  N/A  $12.26   N/A 
FEHB 2   $12.26   N/A  $12.26   $37.13   N/A 
FEHB 3   $87.08   $960.00   $157.82   $159.38   $116.05  
Medicare  $19.97   $19.97   $19.97   $19.97   $5.80  
Medicaid  $19.61   N/A  $19.97   $16.11   $4.29  
83902   FEHB 1   N/A  $5.47   $41.40   N/A  $5.26  
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $12.43   $17.67   $5.00   $40.66   $13.09  
Medicare  $23.58   $23.58   $23.58   $23.58   $6.14  
Medicaid  $23.17   $21.60   $23.58   $19.04   $4.55  
83904   FEHB 1   $16.25   N/A  N/A  N/A  $22.66  
FEHB 2   $13.02   N/A  N/A  N/A  N/A 
FEHB 3   $44.04   $347.74   $43.22   $1,087.05   $71.88  
Medicare  $18.80   $18.80   $12.65   $18.80   $18.80  
Medicaid  $18.66   $15.86   $12.65   $15.34   $13.93  
83907   FEHB 1   $30.00   N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $20.64   $16.21   $13.00   $20.56   $13.00  
Medicare  $23.58   $23.58   $23.58   $23.58   $6.14  
Medicaid  $23.42   $19.91   $23.58   $19.25   $4.55  
83909   FEHB 1   $24.21   $30.27   N/A  $6.13   N/A 
FEHB 2   $13.02   N/A  $12.26   $12.26   N/A 
FEHB 3   $21.62   $21.91   $11.65   $24.01   $23.25  
Medicare  $5.64   $3.29/$5.64*   $5.55   $5.64   $5.64  
Medicaid  $5.54   $5.54   $5.55   $4.15   $4.18  
83912   FEHB 1   $5.60   $5.46   $5.25   $17.96   $7.31  
FEHB 2   $4.85   N/A  $5.65   $8.17   $31.86  
FEHB 3   $4.15   $4.95   $14.72   $5.74   $6.26  
Medicare  $23.58   $23.58   $23.58   $23.58   $6.14  
Medicaid  $23.42   $19.91   $23.58   $19.25   $8.75  
83914   FEHB 1   $14.78   $34.30   N/A  $39.97   N/A 
FEHB 2   $19.17   N/A  $12.28   $12.28   N/A 
FEHB 3   $94.32   $232.50   $327.04   $51.03   $232.50  
Medicare  $20.37   $30.14   $20.37   $30.14   $30.14  
Medicaid  $20.00   $25.44   $20.37   $24.32   $22.35  
88271   FEHB 1   $69.27   N/A  N/A  $31.75   N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $76.08   $168.86   $71.75   $40.04   $66.88  
continued on next page 
* Four States (CA, KS, MO, and NY) are divided into multiple Medicare carrier jurisdictions.  Each jurisdiction may have a different price for   
some Current Procedural Terminology codes.  In jurisdictions where prices differ, differences are signified using / between each  
jurisdictions price.  
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 22  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   MD  ME  MI  MN  MO* 
Code  
Medicare  $5.64   $5.64   $5.64   $5.64   $3.29/$5.64*  
Medicaid  $4.27   $5.67   $4.41   $5.64   $3.07  
83890   FEHB 1   $5.94   N/A  N/A  N/A  N/A 
FEHB 2   $4.76   N/A  N/A  N/A  $51.82  
FEHB 3   $5.00   $6.18   $5.89   $8.09   $4.71  
Medicare  $5.64   $5.64   $5.64   $5.64   $3.29/$5.64*  
Medicaid  $4.27   $5.54   $4.41   $5.64   $3.07  
83891   FEHB 1   $5.79   $5.04   N/A  $81.18   $5.78  
FEHB 2   $4.76   $4.56   $4.23   N/A  $5.88  
FEHB 3   $4.95   $5.54   $6.16   $8.09   $4.95  
Medicare  $5.64   $5.64   $5.64   $5.64   $3.29/$5.64*  
Medicaid  $4.27   $5.67   $4.42   $5.64   $3.07  
83892   FEHB 1   $5.25   N/A  N/A  $13.60   $5.25  
FEHB 2   $5.88   N/A  $5.88   N/A  $5.88  
FEHB 3   $9.90   $6.26   $9.72   $8.09   $9.90  
Medicare  $5.64   $5.64   $5.64   $5.64   $3.29/$5.64*  
Medicaid  $4.27   $5.67   $4.41   $5.64   $3.07  
83894   FEHB 1   $5.36   N/A  N/A  $16.15   N/A 
FEHB 2   $4.76   N/A  N/A  N/A  $8.26  
FEHB 3   $5.00   $15.45   $5.60   $8.09   $5.26  
Medicare  $5.64   $5.64   $5.64   $5.64   $3.29/$5.64*  
Medicaid  $4.27   $5.67   $4.41   $5.64   $3.07  
83896   FEHB 1   $5.46   $5.04   N/A  N/A  $5.25  
FEHB 2   $4.76   N/A  N/A  N/A  $9.02  
FEHB 3   $9.90   $20.28   $43.91   $8.87   $11.02  
Medicare  $5.64   $5.64   $5.64   $5.64   $3.29/$5.64*  
Medicaid  $4.27   $5.54   $4.41   $5.64   $3.07  
83897   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   N/A  $9.02   N/A  $41.61   N/A 
Medicare  $14.32   $6.14   $23.58   $23.58   $23.58  
Medicaid  $10.84   $6.03   $15.90   $23.58   $18.07  
83898   FEHB 1   $22.65   N/A  N/A  N/A  N/A 
FEHB 2   $19.91   N/A  $35.97   N/A  $16.22  
FEHB 3   $15.00   $27.28   $31.63   $33.85   $46.00  
Medicare  $28.65   $12.29   $47.18   $47.18   $47.18  
Medicaid  $21.66   $12.20   $36.84   $47.18   $44.06  
83900   FEHB 1   $29.89   $147.00   N/A  $104.55   $104.41  
FEHB 2   $40.36   $24.57   $32.47   N/A  $40.36  
FEHB 3   $12.00   $13.23   $51.52   $42.60   $28.33  
continued on next page 
* Four States (CA, KS, MO, and NY) are divided into multiple Medicare carrier jurisdictions.  Each jurisdiction may have a different price for   
some Current Procedural Terminology codes.  In jurisdictions where prices differ, differences are signified using / between each  
jurisdictions price.  
 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 23  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   MD  ME  MI  MN  MO* 
Code  
Medicare  $14.32   $6.14   $23.58   $23.58   $23.58  
Medicaid  $10.84   $6.03   $18.42   $23.58   $22.02  
83901   FEHB 1   $24.76   $21.08   N/A  N/A  N/A 
FEHB 2   $22.88   $12.31   $12.26   N/A  $12.28  
FEHB 3   $95.00   $88.40   $467.82   $0.90   $114.73  
Medicare  $14.32   $5.80   $19.97   $16.56   $19.97  
Medicaid  $10.39   $5.69   $15.58   $16.56   $18.65  
83902   FEHB 1   $5.26   N/A  N/A  N/A  $5.26  
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $13.10   $46.30   $31.00   $37.08   $20.00  
Medicare  $14.32   $6.14   $23.58   $23.58   $23.58  
Medicaid  $10.84   $6.03   $18.42   $23.58   $22.02  
83904   FEHB 1   $22.66   N/A  N/A  N/A  N/A 
FEHB 2   $12.18   N/A  $35.97   N/A  $44.38  
FEHB 3   $89.79   $186.00   $447.48   $24.61   $31.19  
Medicare  $18.80   $18.80   $6.81   $18.80   $18.80  
Medicaid  $14.21   $18.66   $5.08   $18.80   $17.55  
83907   FEHB 1   N/A  $58.80   N/A  N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $16.21   $20.85   $18.53   $26.97   $19.00  
Medicare  $14.32   $6.14   $23.58   $23.58   $23.58  
Medicaid  $10.84   $6.10   $18.42   $23.58   $22.02  
83909   FEHB 1   $32.17   N/A  N/A  N/A  $52.19  
FEHB 2   $13.49   $12.26   $12.88   N/A  $13.49  
FEHB 3   $14.88   $23.25   $25.76   $17.25   $20.34  
Medicare  $5.64   $5.64   $5.64   $5.64   $3.29/$5.64*  
Medicaid  $5.60   $5.67   $4.14   $5.64   $3.07  
83912   FEHB 1   $5.25   N/A  N/A  $46.75   $5.25  
FEHB 2   $5.60   $8.09   $5.06   N/A  $6.94  
FEHB 3   $5.00   $5.69   $26.70   $30.98   $4.95  
Medicare  $14.32   $6.14   $23.58   $23.58   $23.58  
Medicaid  $10.84   $6.10   $18.42   $23.58   $22.02  
83914   FEHB 1   N/A  $73.80   N/A  N/A  N/A 
FEHB 2   $19.17   $12.26   $12.28   N/A  $12.27  
FEHB 3   $181.30   $232.50   $51.52   $0.90   $142.38  
Medicare  $30.14   $30.14   $20.37   $30.14   $30.14  
Medicaid  $22.80   $31.27   $16.07   $30.14   $28.14  
88271   FEHB 1   N/A  $28.45   N/A  N/A  N/A 
FEHB 2   $41.90   N/A  N/A  N/A  N/A 
FEHB 3   $91.00   $241.66   $93.56   $26.52   $126.12  
continued on next page 
* Four States (CA, KS, MO, and NY) are divided into multiple Medicare carrier jurisdictions.  Each jurisdiction may have a different price for   
some Current Procedural Terminology codes.  In jurisdictions where prices differ, differences are signified using / between each  
jurisdictions price.  
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 24  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   MS  MT  NC  ND  NE 
Code  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.17   $5.64   $5.10   $5.74   $5.64  
83890   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  $36.00   N/A  $28.00  
FEHB 3   $23.00   $5.00   $3.02   $7.00   $10.06  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.17   $5.64   $5.10   $5.74   $5.64  
83891   FEHB 1   $5.94   N/A  $5.94   N/A  $5.04  
FEHB 2   $15.96   $11.76   $5.88   N/A  $10.92  
FEHB 3   $4.95   $2.54   $4.95   $12.61   $9.76  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.17   $5.64   $5.10   $5.74   $5.64  
83892   FEHB 1   $5.94   N/A  $5.46   N/A  $8.04  
FEHB 2   N/A  N/A  $23.50   N/A  $22.50  
FEHB 3   $9.90   $18.64   $9.90   $9.13   $9.76  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.17   $5.64   $5.10   $5.74   $5.64  
83894   FEHB 1   N/A  N/A  $5.94   N/A  N/A 
FEHB 2   $15.96   N/A  $24.00   N/A  $39.00  
FEHB 3   $15.00   N/A  $10.00   N/A  $9.76  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.17   $5.64   $5.10   $5.74   $5.64  
83896   FEHB 1   N/A  N/A  N/A  N/A  $6.54  
FEHB 2   N/A  N/A  $22.00   N/A  $39.00  
FEHB 3   $9.90   $183.17   $9.90   $38.96   $10.28  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.17   $5.64   $5.10   $5.74   $5.64  
83897   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  $10.92  
FEHB 3   N/A  N/A  N/A  N/A  N/A 
Medicare  $23.58   $23.58   $5.80   $23.58   $23.58  
Medicaid  $21.61   $23.58   $5.23   $24.01   $23.58  
83898   FEHB 1   N/A  N/A  N/A  N/A  $22.65  
FEHB 2   $20.00   $83.00   $35.01   N/A  N/A 
FEHB 3   $35.00   $20.51   $10.00   $52.25   $71.50  
Medicare  $47.18   $47.18   $11.58   $47.18   $47.18  
Medicaid  $43.22   $47.17   N/A  $48.02   $47.18  
83900   FEHB 1   $49.69   N/A  $49.69   N/A  N/A 
FEHB 2   N/A  N/A  $12.02   N/A  $55.00  
FEHB 3   $26.24   $20.86   $5.18   $98.45   $60.82  
continued on next page 
 
 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 25  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   MS  MT  NC  ND  NE 
Code  
Medicare  $23.58   $23.58   $5.80   $23.58   $23.58  
Medicaid  $21.61   $23.58   $5.23   $24.01   $23.58  
83901   FEHB 1   $24.85   N/A  $24.85   N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $82.50   $82.76   $52.36   N/A  $167.40  
Medicare  $5.80   $19.97   $5.80   $19.97   $19.97  
Medicaid  $5.31   $19.96   $5.23   $20.33   $19.97  
83902   FEHB 1   N/A  N/A  N/A  N/A  $28.46  
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   N/A  $30.50   $10.00   $43.00   $7.67  
Medicare  $23.58   $23.58   $5.80   $23.58   $23.58  
Medicaid  $21.61   $23.58   $5.23   $24.01   $23.58  
83904   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  $13.02   N/A  N/A 
FEHB 3   $16.52   N/A  $193.05   $78.00   $100.00  
Medicare  $9.83   $18.80   $18.80   $18.80   $18.80  
Medicaid  $9.01   $18.79   $16.98   N/A  $18.80  
83907   FEHB 1   N/A  N/A  N/A  N/A  $58.80  
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $16.21   N/A  $10.00   $20.85   $28.70  
Medicare  $23.58   $23.58   $5.80   $23.58   $23.58  
Medicaid  $21.61   $23.58   $5.23   $24.01   $23.58  
83909   FEHB 1   $24.85   N/A  $31.07   N/A  $3.73  
FEHB 2   N/A  N/A  $13.26   N/A  N/A 
FEHB 3   $23.25   N/A  $2.59   $86.00   $25.41  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.17   $5.64   $5.10   $5.74   $5.64  
83912   FEHB 1   $5.94   N/A  $5.94   N/A  $5.25  
FEHB 2   $15.96   $37.00   $26.30   N/A  $37.00  
FEHB 3   $4.95   $2.54   $4.95   $12.50   $9.76  
Medicare  $23.58   $23.58   $5.80   $23.58   $23.58  
Medicaid  $21.61   $23.58   $5.23   $24.01   $23.58  
83914   FEHB 1   $24.80   N/A  N/A  N/A  $59.79  
FEHB 2   N/A  N/A  $12.59   N/A  $23.00  
FEHB 3   $167.70   $268.63   $82.88   $81.50   $210.00  
Medicare  $30.14   $20.37   $20.37   $30.14   $30.14  
Medicaid  $27.61   $20.37   $18.40   $30.68   $30.14  
88271   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   $30.00   N/A  N/A  N/A  N/A 
FEHB 3   N/A  $182.00   $136.29   $81.44   $520.00  
continued on next page 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 26  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   NH  NJ  NM  NV  NY 
Code  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $3.44   $4.51   $5.64   $2.80   $5.54  
83890   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $5.81   $5.00   $38.01   $4.93   $6.26  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $3.32   $4.51   $5.64   $2.80   $5.54  
83891   FEHB 1   N/A  $5.78   $5.78   $6.72   $10.97  
FEHB 2   N/A  $5.88   $11.91   $5.88   $5.88  
FEHB 3   $6.26   $4.95   $3.94   $5.00   $4.82  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $3.44   $4.51   $5.64   $2.80   $5.54  
83892   FEHB 1   N/A  $5.25   N/A  $5.40   $16.00  
FEHB 2   N/A  $24.00   $5.04   $5.88   $10.94  
FEHB 3   $16.20   $9.90   $7.46   $7.46   $7.84  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $3.44   $4.51   $5.64   $2.80   $5.54  
83894   FEHB 1   N/A  $4.44   N/A  N/A  $16.00  
FEHB 2   N/A  $6.19   $11.91   $24.00   $20.00  
FEHB 3   $6.26   $9.64   $3.94   $10.00   $6.26  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $3.44   $4.51   $5.64   $2.80   $5.54  
83896   FEHB 1   N/A  $5.25   N/A  $5.40   $16.00  
FEHB 2   N/A  $3.94   $8.90   $5.88   $5.88  
FEHB 3   $314.50   $9.90   $7.88   $8.68   $14.04  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $3.32   $4.51   $5.64   $2.80   $5.54  
83897   FEHB 1   N/A  N/A  N/A  N/A  $22.00  
FEHB 2   N/A  $3.00   N/A  N/A  $22.00  
FEHB 3   N/A  $21.13   N/A  $15.00   $8.86  
Medicare  $6.14   $23.58   $23.58   $23.58   $23.58  
Medicaid  $3.75   $18.86   $23.58   $11.72   $15.89  
83898   FEHB 1   N/A  $22.65   $22.65   $22.32   N/A 
FEHB 2   N/A  $35.51   $49.82   $35.01   $35.01  
FEHB 3   $223.74   $35.00   $32.94   $26.53   $41.86  
Medicare  $12.29   $47.18   $47.18   $47.18   $47.18  
Medicaid  $9.76   $37.74   $47.18   $23.42   $31.78  
83900   FEHB 1   N/A  $37.47   $46.03   $67.23   $57.29  
FEHB 2   N/A  $40.36   $40.36   $40.36   $28.46  
FEHB 3   $46.50   $32.08   $32.94   $23.42   $33.61  
continued on next page 
 
 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 27  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   NH  NJ  NM  NV  NY* 
Code  
Medicare  $6.14   $23.58   $23.58   $23.58   $23.58  
Medicaid  $3.62   $18.86   $10.70   $11.72   $15.89  
83901   FEHB 1   N/A  $9.93   N/A  $33.61   $25.42  
FEHB 2   N/A  $22.88   $26.22   $12.27   $12.05  
FEHB 3   $116.25   $121.75   $297.08   $99.12   $129.42  
Medicare  $5.80   $19.97   $10.70   $19.97   $19.97  
Medicaid  $4.55   $15.98   $23.58   $9.92   $13.45  
83902   FEHB 1   N/A  N/A  N/A  $17.15   N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   N/A  $16.93   $7.57   $8.79   $13.98  
Medicare  $6.14   $23.58   $23.58   $23.58   $23.58  
Medicaid  $3.62   $18.86   $23.58   $11.72   $23.42  
83904   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  $35.01  
FEHB 3   $268.64   $46.50   $1,367.08   $89.79   $58.72  
Medicare  $18.80   $18.80   $18.80   $18.80   $18.80/$4.95/$18.80* 
Medicaid  $11.48   $15.04   $18.80   $9.33   $5.54  
83907   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  $47.60   N/A  N/A 
FEHB 3   $17.88   $16.79   $13.12   $24.87   $20.85  
Medicare  $6.14   $23.58   $23.58   $23.58   $23.58  
Medicaid  $3.75   $18.86   $23.58   $11.71   $23.42  
83909   FEHB 1   N/A  $54.12   $18.75   $33.61   $30.27  
FEHB 2   N/A  $13.38   $13.49   $13.49   $13.49  
FEHB 3   $23.25   $19.81   $15.61   $16.24   $23.25  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $4.43   $4.51   $5.64   $2.80   $20.00  
83912   FEHB 1   N/A  $5.25   $5.25   $17.15   $9.47  
FEHB 2   N/A  $15.84   $13.18   $5.88   $5.88  
FEHB 3   $36.47   $5.00   $11.46   $5.00   $5.57  
Medicare  $6.14   $23.58   $23.58   $23.58   $23.58  
Medicaid  $3.75   $18.86   $23.58   $11.71   $23.42  
83914   FEHB 1   N/A  $23.94   $33.02   N/A  $18.20  
FEHB 2   N/A  $13.27   $19.17   $13.68   $13.27  
FEHB 3   $232.50   $383.12   $271.04   $157.95   $232.50  
Medicare  $30.14   $25.47   $30.14   $30.14   $25.47/$20.37/$20.37*  
Medicaid  $18.41   $20.38   $30.14   $14.97   $29.60  
88271   FEHB 1   N/A  N/A  N/A  $30.00   N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   N/A  $109.20   $289.02   $155.94   $150.00  
continued on next page 
* Four States (CA, KS, MO, and NY) are divided into multiple Medicare carrier jurisdictions.  Each jurisdiction may have a different price for   
some Current Procedural Terminology codes.  In jurisdictions where prices differ, differences are signified using / between each  
jurisdictions price.  
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 28  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   OH  OK  OR  PA  RI 
Code  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.37   $5.18   $4.25   $5.54   $3.36  
83890   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   $28.38   N/A  $9.51   $5.88   N/A 
FEHB 3   $5.60   $6.60   $4.86   $4.09   $10.09  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.37   $5.18   $4.25   $4.43   $3.36  
83891   FEHB 1   $5.78   $4.76   $5.90   $4.47   N/A 
FEHB 2   $5.88   $2.69   $5.85   $5.88   N/A 
FEHB 3   $2.60   $7.50   $5.71   $4.02   $4.45  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.37   $5.18   $4.25   $5.00   $3.36  
83892   FEHB 1   N/A  N/A  $5.35   N/A  N/A 
FEHB 2   $6.19   $2.46   N/A  $5.88   N/A 
FEHB 3   $8.46   $12.00   $9.90   $9.90   $16.20  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.37   $5.18   $4.25   $5.00   $3.36  
83894   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   $14.94   $10.64   $17.00   $28.00   N/A 
FEHB 3   $5.60   $7.84   $16.92   $12.06   $16.20  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.37   $5.18   $4.25   $5.54   $3.36  
83896   FEHB 1   $5.25   N/A  N/A  $5.46   N/A 
FEHB 2   $5.88   $2.35   $9.01   $5.88   N/A 
FEHB 3   $28.00   $13.55   $9.90   $9.90   $15.65  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.37   $5.18   $4.25   $4.43   $3.36  
83897   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $66.27   N/A  N/A  $6.26   N/A 
Medicare  $23.58   $23.58   $23.58   $23.58   $23.58  
Medicaid  $22.47   $21.67   $17.77   $22.50   $14.05  
83898   FEHB 1   $22.65   $22.66   $22.31   $23.53   N/A 
FEHB 2   $35.01   $9.84   $29.85   $35.01   N/A 
FEHB 3   $49.04   $64.86   $28.81   $41.86   $345.60  
Medicare  $47.18   $47.18   $47.18   $47.18   $47.18  
Medicaid  $45.43   $43.36   $35.53   $37.47   $28.10  
83900   FEHB 1   $12.07   $31.07   $38.25   $12.29   N/A 
FEHB 2   $40.36   $24.57   $61.82   $40.36   N/A 
FEHB 3   $16.82   $30.45   $48.02   $23.92   $13.63  
continued on next page 
 
 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 29  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   OH  OK  OR  PA  RI 
Code  
Medicare  $23.58   $23.58   $23.58   $23.58   $23.58  
Medicaid  $22.47   $21.67   $17.77   $18.54   $14.05  
83901   FEHB 1   $11.83   $15.65   N/A  $12.28   N/A 
FEHB 2   $28.07   $11.27   $22.32   $30.10   N/A 
FEHB 3   $170.51   $119.00   $24.01   $155.65   N/A 
Medicare  $19.97   $10.70   $12.09   $19.97   $7.62  
Medicaid  $19.02   $9.83   $9.11   N/A  $4.54  
83902   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   N/A  $8.33   N/A  $36.60   N/A 
FEHB 3   $4.44   $17.52   $9.90   $19.00   $6.42  
Medicare  $23.58   $23.58   $23.58   $23.58   $23.58  
Medicaid  $22.47   $21.67   $17.77   $18.54   $14.05  
83904   FEHB 1   N/A  N/A  N/A  $23.54   N/A 
FEHB 2   N/A  N/A  $18.50   $35.01   N/A 
FEHB 3   $293.40   $38.64   N/A  $89.79   N/A 
Medicare  $16.24   $18.35   $18.80   $18.80   $18.80  
Medicaid  $15.64   $16.87   $14.16   $14.93   $11.20  
83907   FEHB 1   N/A  N/A  $58.80   N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $9.18   $15.44   $16.21   $17.88   $33.63  
Medicare  $23.58   $23.58   $23.58   $23.58   $23.58  
Medicaid  $22.72   $21.67   $17.77   $18.74   $14.05  
83909   FEHB 1   $6.03   $30.26   $29.51   $6.13   N/A 
FEHB 2   $12.26   $12.26   $16.70   $9.51   N/A 
FEHB 3   $11.65   $23.25   $40.68   $11.96   $345.60  
Medicare  $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.37   $5.18   $4.25   $5.54   $3.36  
83912   FEHB 1   $5.25   $10.73   $5.46   $4.19   N/A 
FEHB 2   $5.88   $2.92   $33.32   $5.88   N/A 
FEHB 3   $6.10   $7.84   $34.17   $20.78   $5.50  
Medicare  $23.58   $23.58   $23.58   $23.58   $23.58  
Medicaid  $22.72   $21.67   $17.77   N/A  $14.05  
83914   FEHB 1   $6.03   $27.09   $26.71   $6.14   N/A 
FEHB 2   $12.69   $12.28   $24.14   $12.26   N/A 
FEHB 3   $210.25   $232.50   $117.38   $383.12   $5.88  
Medicare  $30.14   $30.14   $30.14   $16.97   $30.14  
Medicaid  $28.71   $27.70   $22.70   N/A  $17.96  
88271   FEHB 1   $28.46   N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $18.62   $191.72   $26.52   $150.36   N/A 
continued on next page 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 30  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   SC  SD  TN  TX  UT 
Code  
Medicare  $5.64   $5.64   $5.64   $5.64   $4.48  
Medicaid  $5.03   $5.54   N/A  $5.51   $3.85  
83890   FEHB 1   $3.36   $51.82   N/A  $9.82   $5.94  
FEHB 2   N/A  N/A  N/A  $36.00   $19.23  
FEHB 3   $5.00   $8.25   $4.93   $5.00   $5.00  
Medicare  $5.64   $5.64   $5.64   $5.64   $4.48  
Medicaid  $5.03   $5.54   N/A  $5.51   $4.33  
83891   FEHB 1   $5.94   $34.52   $5.86   $5.86   $5.94  
FEHB 2   $4.64   N/A  $24.00   $5.88   $5.88  
FEHB 3   $4.95   $4.95   $4.95   $4.86   $5.00  
Medicare  $5.64   $5.64   $5.64   $5.64   $4.48  
Medicaid  $5.03   $5.54   N/A  $5.51   $3.85  
83892   FEHB 1   $5.18   $33.02   $5.60   $5.94   $5.19  
FEHB 2   N/A  N/A  $5.88   $12.75   $5.88  
FEHB 3   $9.90   $9.90   $9.90   $9.90   $7.63  
Medicare  $5.64   $5.64   $5.64   $5.64   $4.48  
Medicaid  $5.03   $5.54   N/A  $5.51   $3.85  
83894   FEHB 1   N/A  $58.20   $5.94   $5.19   $5.94  
FEHB 2   N/A  N/A  N/A  $24.00   $24.00  
FEHB 3   $9.00   $15.00   $5.00   $6.88   $5.00  
Medicare  $5.64   $5.64   $5.64   $5.64   $4.48  
Medicaid  $5.03   $5.54   N/A  $5.51   $4.22  
83896   FEHB 1   $5.46   $20.26   $5.25   $11.77   $11.75  
FEHB 2   $5.04   N/A  N/A  $6.02   $17.46  
FEHB 3   $9.90   $8.25   $13.49   $19.80   $9.12  
Medicare  $5.64   $5.64   $5.64   $5.64   $4.48  
Medicaid  $5.03   $5.54   N/A  $5.51   $4.33  
83897   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   N/A  N/A  $7.03   $7.33   N/A 
Medicare  $23.58   $23.58   $5.80   $14.32   $20.95  
Medicaid  $21.04   $23.17   N/A  $14.00   $18.56  
83898   FEHB 1   $25.96   $58.20   $24.85   $24.85   $24.85  
FEHB 2   $17.05   N/A  $317.89   $35.01   $35.51  
FEHB 3   $47.10   $34.53   $7.08   $20.69   $23.17  
Medicare  $47.18   $47.18   $11.58   $28.65   $41.87  
Medicaid  $42.10   $46.84   N/A  $27.99   N/A 
83900   FEHB 1   $38.91   N/A  $70.35   $49.69   $108.00  
FEHB 2   $147.00   N/A  $38.92   $29.89   $40.36  
FEHB 3   $20.83   $28.68   $8.25   $16.94   $41.49  
continued on next page 
 
 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 31  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   SC  SD  TN  TX  UT 
Code  
Medicare  $23.58   $23.58   $5.80   $14.32   $20.95  
Medicaid  $21.04   $23.17   N/A  $14.00   $20.29  
83901   FEHB 1   $24.80   N/A  N/A  $18.54   $22.32  
FEHB 2   $21.08   N/A  $34.01   $12.26   N/A 
FEHB 3   $100.49   $18.25   $59.59   $110.11   $125.58  
Medicare  $19.97   $19.97   $5.80   $14.32   $19.97  
Medicaid  $17.82   $19.61   N/A  $14.00   $46.89  
83902   FEHB 1   N/A  N/A  $5.26   $29.65   $23.54  
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $31.00   $9.90   $4.57   $16.94   $25.00  
Medicare  $23.58   $23.58   $5.80   $14.32   $20.95  
Medicaid  $21.04   $23.17   N/A  $14.00   $20.29  
83904   FEHB 1   $14.05   N/A  N/A  $22.66   $20.60  
FEHB 2   $13.02   N/A  N/A  $35.01   N/A 
FEHB 3   $54.42   N/A  $15.34   $64.14   $134.69  
Medicare  $18.80   $18.80   $18.80   $18.80   $18.80  
Medicaid  $16.77   $18.66   N/A  $18.36   N/A 
83907   FEHB 1   N/A  N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $17.55   N/A  $18.53   $16.21   $17.88  
Medicare  $23.58   $23.58   $5.80   $14.32   $20.95  
Medicaid  $21.04   $23.42   N/A  $14.00   N/A 
83909   FEHB 1   $22.95   $168.89   $35.18   $24.85   $18.75  
FEHB 2   $13.02   N/A  $18.74   $12.26   $13.49  
FEHB 3   $13.32   $21.50   $5.90   $8.47   $20.45  
Medicare  $5.64   $5.64   $5.64   $5.64   $4.48  
Medicaid  $5.03   $5.54   N/A  $5.51   $4.33  
83912   FEHB 1   $5.36   $56.58   $5.36   $5.36   $5.94  
FEHB 2   $11.09   N/A  $17.64   $5.88   $5.88  
FEHB 3   $4.95   $7.00   $5.00   $4.95   $5.00  
Medicare  $23.58   $23.58   $5.80   $14.32   $20.95  
Medicaid  $21.04   $23.42   N/A  $14.00   N/A 
83914   FEHB 1   $24.85   N/A  N/A  $24.85   $34.17  
FEHB 2   $73.80   N/A  $18.74   $12.28   $19.17  
FEHB 3   $234.20   $219.00   $132.16   $271.04   $82.88  
Medicare  $30.14   $30.14   $20.37   $30.14   $20.37  
Medicaid  $26.89   $3.50   N/A  $29.45   $19.73  
88271   FEHB 1   N/A  N/A  N/A  N/A  $30.00  
FEHB 2   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $179.60   $37.00   $63.23   $107.67   $127.32  
continued on next page 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 32  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   VA  VT  WA  WI  WV  WY 
Code  
Medicare  $5.51   $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.14   $5.40   $5.74   $5.60   $5.08   $5.04  
83890   FEHB 1   N/A  N/A  $5.25   N/A  N/A  N/A 
FEHB 2   $1.98   N/A  $4.40   $45.00   N/A  N/A 
FEHB 3   $4.95   $5.45   $5.00   $8.36   $7.20   N/A 
Medicare  $5.51   $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.14   $5.40   $5.74   $5.60   $5.08   N/A 
83891   FEHB 1   $5.79   N/A  $5.78   N/A  $5.78   N/A 
FEHB 2   $5.88   N/A  $5.88   $26.95   $24.00   N/A 
FEHB 3   $5.00   $16.08   $5.17   $6.31   $7.20   $5.91  
Medicare  $5.51   $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.14   $5.40   $5.74   $5.60   $5.08   $5.04  
83892   FEHB 1   $5.25   N/A  $5.25   N/A  N/A  N/A 
FEHB 2   $5.88   N/A  $13.02   $14.64   N/A  N/A 
FEHB 3   $9.90   $16.62   $14.85   $5.74   $14.40   $9.72  
Medicare  $5.51   $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.14   $5.40   $5.74   $5.60   $5.08   $5.04  
83894   FEHB 1   $5.70   N/A  N/A  N/A  $5.26   N/A 
FEHB 2   $5.45   N/A  $24.00   $52.37   N/A  N/A 
FEHB 3   $5.09   $16.62   $16.92   $5.74   $14.40   $13.90  
Medicare  $5.51   $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.14   $5.40   $5.74   $5.60   $5.08   $5.04  
83896   FEHB 1   $5.25   N/A  $5.25   N/A  N/A  N/A 
FEHB 2   $5.88   N/A  $8.27   $25.20   N/A  N/A 
FEHB 3   $19.80   $337.94   $10.03   $11.01   $43.20   $11.14  
Medicare  $5.51   $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.14   $5.40   $5.74   $5.60   $5.08   $5.04  
83897   FEHB 1   N/A  N/A  N/A  N/A  N/A  N/A 
FEHB 2   $10.14   N/A  N/A  N/A  N/A  N/A 
FEHB 3   $4.95   N/A  N/A  N/A  N/A  N/A 
Medicare  $23.58   $6.14   $23.58   $23.58   $23.58   $23.58  
Medicaid  $18.53   $5.93   $24.01   $3.73   $21.22   $21.08  
83898   FEHB 1   $23.53   N/A  N/A  N/A  N/A  N/A 
FEHB 2   $19.91   N/A  $35.01   $102.06   $35.01   N/A 
FEHB 3   $18.14   $44.90   $39.53   $24.01   $29.25   $345.60  
Medicare  $47.18   $12.29   $47.18   $47.18   $47.18   $47.18  
Medicaid  $44.50   $34.86   $36.50   $42.58   $42.46   $42.16  
83900   FEHB 1   $28.25   N/A  $101.83   N/A  $46.55   N/A 
FEHB 2   $40.36   N/A  $46.84   $202.75   $37.47   N/A 
FEHB 3   $5.18   $46.50   $44.82   $46.50   $58.50   $47.34  
continued on next page 
 
 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 33  Marilyn Tavenner 
 
Table D-1: Medicare Clinical Laboratory  Fee Schedule, State Medicaid Program, and 
Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 
(Continued) 
Current  State 
Procedural 
Insurer 
Terminology   VA  VT  WA  WI  WV  WY 
Code  
Medicare  $23.58   $6.14   $23.58   $23.58   $23.58   $23.58  
Medicaid  $13.37   $5.93   $24.01   $23.40   $21.22   $21.08  
83901  
FEHB 1   $15.06   N/A  N/A  N/A  $24.76   N/A 
FEHB 2   $21.40   N/A  $4.00   $51.82   $34.01   N/A 
FEHB 3   $70.00   N/A  $93.91   $26.41   $351.00   $162.72  
Medicare  $5.51   $5.80   $12.09   $14.53   $19.97   $19.97  
Medicaid  $5.14   $5.57   $12.31   $14.41   $17.97   $17.85  
83902   FEHB 1   $13.63   N/A  $5.26   N/A  $5.26   N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A  N/A 
FEHB 3   $8.58   $19.00   $9.90   $31.00   $9.90   $31.00  
Medicare  $23.58   $6.14   $23.58   $23.58   $23.58   $23.58  
Medicaid  $13.37   $5.93   $24.01   $23.40   $21.22   $21.08  
83904   FEHB 1   $22.66   N/A  N/A  N/A  $22.66   N/A 
FEHB 2   $29.00   N/A  $24.02   N/A  N/A  N/A 
FEHB 3   $54.42   $67.35   $134.69   $34.41   $81.36   N/A 
Medicare  $16.36   $18.80   $18.80   $10.51   $18.80   $12.27  
Medicaid  $15.43   $34.86   $14.54   $9.49   $16.92   $10.96  
83907   FEHB 1   N/A  N/A  N/A  N/A  N/A  N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A  N/A 
FEHB 3   $16.21   $17.88   $17.88   N/A  N/A  $24.32  
Medicare  $23.58   $6.14   $23.58   $23.58   $23.58   $23.58  
Medicaid  $22.25   $5.93   $18.25   $21.29   $21.22   $21.08  
83909   FEHB 1   $18.74   N/A  N/A  N/A  $23.25   N/A 
FEHB 2   $13.49   N/A  $16.75   $17.12   $18.74   N/A 
FEHB 3   $2.59   $34.08   $33.17   $34.95   $29.25   $345.60  
Medicare  $5.51   $5.64   $5.64   $5.64   $5.64   $5.64  
Medicaid  $5.20   N/A  $5.74   $5.60   $5.08   $5.04  
83912   FEHB 1   $5.25   N/A  $5.25   N/A  $5.25   N/A 
FEHB 2   $5.88   N/A  $5.88   $54.95   $40.00   N/A 
FEHB 3   $5.00   $42.82   $5.64   $6.31   $29.25   $5.57  
Medicare  $23.58   $6.14   $23.58   $23.58   $23.58   $23.58  
Medicaid  $22.25   $34.86   $18.25   $21.29   $21.22   $21.08  
83914   FEHB 1   $15.13   N/A  N/A  N/A  N/A  N/A 
FEHB 2   $19.17   N/A  $6.00   N/A  $18.74   N/A 
FEHB 3   $82.88   $479.26   $229.04   $102.35   $294.03   $99.37  
Medicare  $30.14   $30.14   $30.14   $20.37   $30.14   $30.14  
Medicaid  $28.12   $38.34   $23.32   $20.22   $27.13   $26.94  
88271   FEHB 1   $28.45   N/A  N/A  N/A  $28.45   N/A 
FEHB 2   N/A  N/A  N/A  N/A  N/A  N/A 
FEHB 3   $69.03   N/A  $116.95   $25.00   $138.88   $239.44  
Source:  Office of  Inspector General analysis of Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and FEHB Payment 
Rates, 2011. 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 34  Marilyn Tavenner 
 
APPENDIX E  
 
Table E-1:  State Medicaid Program Payment Rates for Selected Genetic Tests by Test 
Name  
State 
Test 
CA   DE   IL   IA  MA  MN   PA   VA  
BCR/ABL1 
Translocation        $867          
Analysis  
BRCA1 Gene 
$3,340  $3,120   $3,030  $4,498  $2,731     $1,000   $3,120  
Analysis  
BRCA2 Gene 
$3,340  $3,120   $2,770  $4,947       $1,000    
Analysis  
CFTR Gene 
$180                
Analysis  
ChemoFx         $1,408          
F2 Gene 
      $132          
Analysis  
KRAS Gene 
      $421          
Analysis  
MLH1 Gene 
               
Analysis  
MSH2 Gene  
               
Analysis  
OncoTypeDX       $2,050       $3,416      
PathFinderTG   $2,732                
Pathwork Tissue 
      $927          
of Origin  
VeriStrat         $25     
Note: Payment rates rounded to the nearest whole dollar. 

Source:  Office of  Inspector General analysis of State Medicaid program survey responses, 2011.
 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 35  Marilyn Tavenner 
 
APPENDIX F  
 
Table F-1:  Federal Employee Health Benefits Plan Median Payment Rates for Selected  
Genetic Tests by Test Name 
Test 
State  BCR/ABL1   CFTR  F2 Gene  HFE 
AlloMap  Translocation  Gene  ChemoFx   Gene 
Analysis  
Analysis   Analysis   Analysis  
Alabama  $13      $95 
Alaska         $187      
Arizona   $20    $18  $75 
Arkansas         $150      
California   $50  $18  $105      
Colorado   $11      $93 
Connecticut      $38  $114   $38   
Delaware  $13      $92 
District of Columbia   $6    $18  $73 
Florida   $117     $7  $98 
Georgia   $177       $95 
Hawaii         $109      
Idaho        $130      
Illinois   $80  $93  $12  $99 
Indiana  $455       $72 
Iowa   $227       $150      
Kansas   $270       $124      
Kentucky   $18    $35  $57 
Louisiana   $171       $126      
Maine   $42      $65 
Maryland  $8    $12  $73 
Massachusetts         $98 
Michigan   $102       $60 
Minnesota   $16    $1  $125      
Mississippi         $131      
Missouri   $130       $105      
Montana        $88 
Nebraska         $132      
Nevada   $2  $12  $116      
New Hampshire         $125      
New Jersey   $90  $13    $101      
New Mexico  $207       $88 
New York  $10      $86 
North Carolina   $10    $30  $95 
North Dakota   $115  $93    $168   $7   
Ohio   $35  $35  $83  $14   
Oklahoma   $8  $10  $131      
Oregon   $40  $27  $121   $9  $6 
Pennsylvania   $90      $54 
Rhode Island   $3,658       $106      
South Carolina   $9      $123      
South Dakota   $788       $187      
Tennessee         $131   $26   
Texas   $9    $6  $115      
Utah         $53  $9   
Vermont        $182      
Virginia   $428     $18  $88  $9   
Washington      $47  $124   $8   
West Virginia   $8    $7  $93 
Wisconsin   $758     $6  $143     $51 
Wyoming        $130      
continued on next page 
Note: Payment rates rounded to the nearest whole dollar. 
 
   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests  Page 36  Marilyn Tavenner 
 
APPENDIX F  
 
Table F-1:  Federal Employee Health Benefits Plan Median Payment Rates for Selected  
Genetic Tests by Test Name (Continued) 
Test 
State  MSH2  Oncotech   Pathwork 
Gene  PathFinderTG   Tissue of  VeriStrat 
EDR 
Analysis   Origin  
Alabama  $276   $240   $10  $8 
Alaska         $38   
Arizona    $5,640   $5,640   $10  $20 
Arkansas    $3,760   $3,760   $8   
California     $70  $70  $18  $50 
Colorado    $3,760   $1,885   $10  $11 
Connecticut         $14   
Delaware    $13  $17  $13 
District of Columbia    $25  $15  $5  $6 
Florida    $3,760   $3,760   $19  $48 
Georgia    $232   $5,640   $10   
Hawaii     $44  $44  $14   
Idaho        $18   
Illinois     $360  $60  $17  $29 
Indiana  $5,170   $4,935   $15  $455  
Iowa   $65  $1,880   $422   $14  $227  
Kansas    $198   $422   $18  $422  
Kentucky     $138  $18  $12  $18 
Louisiana    $9  $9  $16  $171  
Maine    $42    $6   
Maryland    $470  $66  $10  $8 
Massachusetts         $16   
Michigan       $102   $27  $102  
Minnesota    $313   $286   $15  $16 
Mississippi    $5,640   $5,640   $20   
Missouri    $130   $422   $18  $422  
Montana        $19   
Nebraska    $8  $8  $10   
Nevada   $1,207  $8  $5  $10  $2 
New Hampshire         $27   
New Jersey    $3,029   $418   $17  $90 
New Mexico  $207     $11   
New York    $3,760  $62  $15  $10 
North Carolina      $10  $10  $10 
North Dakota    $113   $115   $27  $115  
Ohio     $767  $35  $17  $35 
Oklahoma    $13  $8  $17  $8 
Oregon      $40  $21  $40 
Pennsylvania     $1,880  $93  $18  $90 
Rhode Island    $2,350   $3,004   $14  $3,658  
South Carolina    $5,640   $9  $11  $9 
South Dakota    $774   $760   $10   
Tennessee    $3,055   $3,055   $10   
Texas    $940   $940   $10  $9 
Utah         $10   
Vermont        $28   
Virginia    $686   $2,820   $8  $1,869  
Washington    $5,640   $5,640   $15   
West Virginia       $8  $29  $8 
Wisconsin    $462   $758   $11  $758  
Wyoming  $1,443   $1,443   $15   
Source:  Office of  Inspector General analysis of Federal Employee Health Benefits plan payment rates, 2011.   
OEI-07-11-00011   Coverage and Payment for Genetic Laboratory Tests