Genetic Testing

Effective July 1 2017, Prevea360 Health Plan will have updated medical policies for Genetic Testing. Key notes to consider:

  • Current Medical Policy MP9012 will serve as the general policy for genetic testing and will provide links to specific genetic tests.
  • If a medical policy does not refer to a specific genetic test, applicable evidenced based guidelines and a prior authorization will be required.
  • Authorization, Genetic Counseling and Medical Necessity requirements may be test specific, as identified within each medical policy.
  • Medical necessity criteria will be applied to HMO, POS, PPO, and ASO members.

 

The Chart below identifies NEW medical policy components, which may vary by test. See individual policy for details:

Medical Policy Medical Policy # Policy Type Authorization Required Genetic Counseling Required Medical Necessity Criteria
General Genetic Testing Policy MP9012 General Some   X
Hereditary Cardiac Disease & Arrhythmias MP9472 Cardiac X X X
Thrombophilia MP9473 General     X
Reproductive Carrier Screening & Prenatal Diagnosis MP9477 Maternal-Fetal Some   X
BRCA1 and BRCA2 MP9478 Cancer X X X
Pharmacogenetic Testing MP9479 General X   X
Peutz-Jeghers Syndrome MP9480 Cancer X X X
Hearing Loss & Usher Syndrome MP9481 General X   X
Polyposis MP9482 Cancer X X X
Multiple Endocrine Neoplasia, Type 1 & 2 MP9483 Cancer X X X
Diffuse Gastric Cancer – CDH1 Gene MP9484 Cancer X X X
Li-Fraumeni Syndrome – TP53 Gene MP9485 Cancer X X X
Somatic Tumor Markers, Gene Expression Assays for Hematology/Oncology Indications MP9486 General     X
Lynch Syndrome MP9487 Cancer X X X
Cowden Syndrome – PTEN Gene MP9488 Cancer X X X
Huntington Disease MP9490 General X X X
Chromosomal Microarray Analysis MP9491 General     X
Covered Genetic Testing that does not Require a Prior Authorization

View a full list of Medical Policies related to Genetic Testing

Genetic Testing - Prior Authorization

  • If you are a Prevea360 Health Plan Provider Portal user, please submit prior authorization requests via the provider portal
  • If you do not have access to submit prior authorization via the provider portal, please fax the Genetic Testing prior authorization form to the number indicated on the form

Genetic Counseling Requirement

Certain tests require pre-test and post- test genetic counseling. Prior authorization is not required for referrals to a genetic counselor.

Genetic Counseling Resources

St. Vincent Genetic Counseling department can provide genetic counseling for Prevea360 Health Plan members. Members can be referred to St. Vincent Genetic Counseling at 920-433-8559 (fax 920-431-3138). Additionally, if there are in-network providers who employ genetic counselors may continue to use a current process that may be in place to comply with Prevea360 Health Plan’s updated genetics testing medical policies where genetic counseling is required.

Prevea360 Health Plan recognizes the limited accessibility of genetic counselors. As such, we have partnered with InformedDNA (IDNA) to provide telephonic genetic counseling services for Prevea360 Health Plan members. The goal is to improve member satisfaction and ease the burden for our providers. If no genetic counselors are available within your organization or there is an access issue, Prevea360 Health Plan’s member may be referred to InformedDNA (IDNA). Please use the IDNA Cancer Genetic Counseling Referral Form or the Cardiac Genetic Counseling Referral Form to refer to IDNA.