Vermont Medicaid requires prior authorization for some genetic testing codes, and the ordering clinician requests it on this DVHA form. It asks for the CPT and ICD-10 codes, the suspected diagnosis, and documentation showing how the results will directly change the member's medical management. DVHA's clinical unit reviews it, and missing documentation delays the review.
The ordering clinician or a genetic counselor completes the form, including the requesting provider and the supplying provider, each with Medicaid provider number, NPI and taxonomy, plus the codes and medical information.
Download the current version from the source each time; forms change without notice.
Genetic Testing Prior Authorization
This form is a Word template, not a PDF. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Documentation of how results will directly affect the member's medical management, results of related past genetic testing, personal or family history suggesting a mutation, supporting literature or guidelines such as NCCN or ACOG, and results of first-tier testing that failed to give a diagnosis.
No. DVHA posts it as a Word document, listed under laboratory and radiology on its clinical prior authorization forms page; the current version is dated August 2026. Complete it, then fax or securely email it to the DVHA Clinical Unit with the clinical documentation.