SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 1 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
POLICY:
Genetic Testing is required to be scheduled prior to patients presenting to the laboratory
for collection. This process will allow the scheduler to obtain the prior pre-authorization if
needed from the ordering provider.
Genetic testing is typically an expensive test and many insurance companies require
pre-authorization prior to performing. The physician ordering the test is required to
obtain the authorization number from the insurance company or meet the requirements
for medical necessity if no authorization is needed.
The patient cannot have the testing performed without the information provided above.
If the patient presents without the information the ordering physician will be contacted to
provide the authorization or asked to complete an Advanced Beneficiary Notice (ABN)
form. The signed ABN holds the patient responsible for charges if the insurance does
not cover the testing.
The following insurances and requirements are included in this policy:
 Highmark
 UPMC
 Cigna
 Aetna
 Gateway
 Medicare
 FirstCare PPO
 HealthAmerica Coventry
Types of Genetic Testing:
Newborn Screening
Newborn screening is used just after birth to identify genetic disorders that can
be treated early in life.
Diagnostic Testing
Diagnostic testing is used to identify or rule out a specific genetic or
chromosomal condition. In many cases, genetic testing is used to confirm a
diagnosis when a particular condition is suspected based on physical signs and
symptoms. Diagnostic testing can be performed before birth or at any time during
a person’s life.
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 2 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Carrier Testing
Carrier testing is used to identify people who carry one copy of a gene mutation
that, when present in two copies, causes a genetic disorder. This type of testing
is offered to individuals who have a family history of a genetic disorder and to
people of certain ethnic groups with an increased risk of specific genetic
conditions.
Prenatal testing
Prenatal testing is used to detect changes in the fetus’s genes or chromosomes
before birth. This type of testing is offered during pregnancy if there is an
increased risk that the baby will have a genetic or chromosomal disorder. In
some cases, prenatal testing can lessen a couple’s uncertainty or help them
make decisions about a pregnancy.
Currently Available DNA-Based Gene Tests:
 Alpha-1-antitrypsin deficiency (AAT; emphysema and liver disease)
 Amyotrophic lateral sclerosis (ALS; Lou Gehrig’s Disease; progressive motor
function loss leading to paralysis and death)
 Alzheimer’s disease (APOE; late-onset variety of senile dementia)
 Ataxia telangiectasia (AT; progressive brain disorder resulting in loss of muscle
control and cancers)
 Gaucher disease (GD; enlarged liver and spleen, bone degeneration)
 Inherited breast or ovarian cancer (BRCA1/BRCA2; early onset tumors of breasts
and ovaries)
 Hereditary nonpolyposis colon cancer (CA; early-onset tumors of colon and
sometimes other organs)
 Central core disease (CCD; mild to severe muscle weakness)
 Charcot-Marie-Tooth (CMT; loss of feeling in ends of limbs)
 Congenital adrenal hyperplasia (CAH; hormone deficiency; ambiguous genitalia
and male pseudohermaphroditism)
 Cystic fibrosis (CF; disease of lung and pancreas resulting in thick mucous
accumulations and chronic infections)
 Duchenne muscular dystrophy/Becker muscular dystrophy (DMD, sever to mild
muscle wasting, deterioration, weakness)
 Dystonia (DYT; muscle rigidity; repetitive twisting movements)
 Emanuel syndrome (severe mental retardation, abnormal development of the
head, heart and kidney problem)
 Fanconi anemia, group C (FA; anemia, leukemia, skeletal deformities)
 Factor V Leiden (FVL; blood-clotting disorder)
 Fragile X Syndrome (FRAX; leading cause of inherited mental retardation)
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 3 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
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REVISED:
Galactosemia (GALT; metabolic disorder affects ability to metabolize galactose)
Hemophilia A and B (HEMA and HEMB; bleeding disorders)
Hereditary hemochromatosis (HFE; excess iron storage disorder)
Huntington’s disease (HD, usually midlife onset; progressive, lethal, degenerative
neurological disease)
Marfan syndrome (FBNI; connective tissue disorder, tissues of ligaments, blood
vessel walls, cartilage, heart valves and other structures abnormally weak)
Mucoplysaccharidosis (MPS; deficiency of enzymes needed to break down long
chain sugars called glycosaminoglycans; corneal clouding, joint stiffness, heart
disease, mental retardation)
Myotonic dystrophy (MD; progressive muscle weakness, most common form of
adult muscular dystrophy)
Neurofibromatosis type 1(NF1; multiple benign nervous system tumors that can
be disfiguring; cancers)
Phenylketonuria (PKU; progressive mental retardation due to missing enzyme;
correctable by diet)
Polycystic kidney disease (PKD1, PKD2; cysts in the kidneys and other organs)
Adult polycystic kidney disease (APKD; kidney failure and liver disease)
Prader Willi/Angleman syndromes (PW/A; decreased motor skills, cognitive
impairment early death)
Sickle cell disease (SS; blood cell disorder; chronic pain and infections)
Spinocerebellar ataxia, type 1(SCA1; involuntary muscle movements, reflex
disorders, explosive speech)
Spinal muscular atrophy (SMA; severe, usually lethal progressive musclewasting disorder in children)
Tay-Sachs disease (TS; fatal neurological disease of early childhood, seizures,
paralysis)
Thalassemias (THAL; anemias-reduced red blood cell levels)
Timothy syndrome (CACNA1C; characterized by sever cardiac arrhythmia,
webbing of the fingers and toes called syndactyly, autism)
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 4 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
PROCEDURE:
Prior to genetic testing being performed the Physician’s office must contact the
scheduling department at 724-357-7075. The scheduling staff will require the office to
obtain the proper authorization if needed prior to calling. The authorization and ordering
script must be faxed at the time of scheduling.
The ordering script and authorization form will be scanned into Meditech for other
departments to prepare for the patient arrival by the scheduling staff.
Appointments will have a two-day lead time and will only be scheduled Monday –
Thursday 0630 to 1600 at the IRMC OP Lab at 835 Hospital Road location. Laboratory
staff will have ample time to determine specimen requirements based on the test
ordered and provide specimen integrity for shipping to the appropriate reference lab.
Meditech Scheduling Software is programmed to flag the scheduling staff with the
following message:
THIS PROCEDURE WILL MORE THAN LIKELY REQUIRE A PRE-AUTHORIZATION.
OFFICES MUST CALL INSURANCE TO VERIFY PATIENT PLAN REQUIREMENTS
PER CPT.
Physician’s office will be required to provide one of the following upon scheduling:

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Authorization number
No authorization needed as per insurance
o Name of the representative giving information from insurance provider
o Info provided by representative
o Who called (from Physician’s office)
o Date and time called
No authorization and meeting medical necessity as per policy/procedure
The scheduler will place either the AUTHORIZATION # or NONE in the authorization
field.
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 5 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Patient presents with authorization or verification:
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Testing can be ordered, collected and referred to the proper reference laboratory.
Verify if multiple testing is ordered that all requiring authorizations are denoted on
the authorization form. If not an additional authorization may need to be obtained.
Patient presents without authorization:
The genetic test listing below denotes requirements for pre-authorizations prior to
collection.
Contact the physician office and inform pre-authorization form must first be obtained
prior to collection of specimen.
 The physician office can fax the form to the collection site
 Patient may need to return to have testing completed until authorization is
received
 If patient is unwilling to return, they can complete an ABN form with the
understanding they are responsible financially for any charges to IRMC
 The authorization or ABN must be scanned into the system along with the
physician order
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 6 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Highmark Requirements
Genetic testing performed on patients with no current evidence or manifestation of
genetic disease (i.e., asymptomatic) is considered genetic screening and is noncovered except for those groups/programs that specifically identify coverage in benefits.
This includes genetic testing performed to determine susceptibility or predisposition to
diseases such as cancer and heart disease and genetic testing for carrier identification
to determine if a person is a “carrier” of an abnormal gene.
Highmark requires a pre-authorization form for the following tests:
 CYP2C19 (Drug Metabolism)
 CYP2D6 (Drug Metabolism)
 CYP2C9 (Drug Metabolism)
 CPT 81275 KRAS Gene Mutation
 CPT 81280 Long QT Syndrome Full Gene Sequence
 CPT 81281 Long QT Syndrome Known Familial Sequence Variant
 CPT 81282 Long QT Syndrome Deletion/Duplication Variants
 CPT 81401 TPMT Genotyping
 CPT 81403 Pancreatitis Mutation
 CPT (Dependent on Agent) Infectious Agent Genotype
 CPT 81479 Unlisted Pathology Test
 CPT 83520x5, 88347, 88347x2, 81401 Chrons Prognostic
 CPT 81257, 81401, 81403, 81404 Hgb Molecular
 Exam And Selection Of Retrieved Archival
The following testing is covered for symptomatic patients. The testing is only covered for
asymptomatic patients when the patient’s contract covers genetic testing. This is not an
all-inclusive list.
 CPT: 81292, 81293, 81294, 81295, 81296, 81298, 81299, 81300, 81301, 81317,
81318, 81319) Inherited susceptibility to colon cancer
 CPT: 81220, 81221, 81222, 81223, 81224 Cystic Fibrosis Testing
 CPT: 81256 Hemochromatosis
 CPT: 81257 Alpha-Thalessemia
 CPT: 81255 Tay-Sachs Disease
 CPT: 81251 Gaucher Disease
 CPT: 81330 Niemann-Pic Disease
 CPT: 81241 Factor V Leiden Thrombophilia
 CPT: 81243, 81244 Fragile X Syndrome
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 7 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Genetic testing for prenatal and preconceptual carrier screening is considered medically
necessary for individuals of Ashkenazi Jewish ancestry in accordance with the
American College of Medical Genetics guidelines as follows:
 Bloom Syndrome
 Canavan Disease
 Cystic Fibrosis
 Dihydrolipoamide Dehydrogenase Deficiency (DLD)
 Familial Dysautonomia (FD)
 Familial Hyperinsulinism (FHI)
 Fanconi Anemia Type C
 Gaucher Disease Type 1
 Glycogen Storage Disease type 1A
 Joubert Syndrome
 Maple Syrup Urine Disease
 Mucolipidosis IV
 Nemaline Myopathy (NM)
 Niemann-Pic Disease Type A
 Spinal Muscular Atrophy
 Usher Syndrome Type III and Type 1F
 Walker-Warburg Syndrome
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 8 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
UPMC Health Plan Requirements
UPMC Health Plan requires prior authorization for the following genetic testing.
Authorization should be approved based on the following indications. However, if testing
is being performed based on the limitations medical necessity may not be proven.
CPT Code:
81280 Long QT Syndrome Full Gene Sequence
81281 Long QT Syndrome Known Familial Sequence Variant
81282 Long QT Syndrome Deletion/Duplication Variants
CPT Codes: Breast and Ovarian Cancer Testing
81211 BRCA1/BRCA2 Gene Analysis Common Variant
81212 BRCA1/BRCA2 185/5385/6174 Variants
81213 BRCA1/BRCA2 Uncommon Variant
81214 BRCA1 Gene Analysis Common Variants
81215 BRCA1 Known Familial Variant
81216 BRCA2 Gene Analysis Common Variants
81217 BRCA2 Known Familial Variant
BRACAnalysis® Rearrangement Test (BART) (Myriad Genetic
Laboratories, Inc., Salt Lake City, UT)
Inherited Colorectal Cancers: (HPNCC, FAP and MAP testing)
CPT Codes: Cystic Fibrosis Testing
81220 CFTR Gene Analysis Common Variants
81221 CFTR Known Familial Variants
81222 CFTR Dup/Del Variants
81223 CFTR Full Gene Sequence
Genetic Testing for Long QT Syndrome:
In order for medical necessity to be established, adequate information must be
furnished by the treating physician. Necessary information includes, but is not limited to:
 Physician’s letter of medical necessity which includes supporting
documentation such as patient symptoms,
 QT interval per EKG and family history with clinical documentation
validating diagnosis.
The Medical Management staff assigned to review obtains the clinical information
according to determine if there is adequate clinical information. If the case does not
meet established criteria, it is referred to a Medical Director. The Medical Director will
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 9 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
then determine if the request service is medically necessary and appropriate. The
Medical Management staff completes the review process and communicates the review
decision according to the Timeliness of UM Decisions policy for the member’s benefit
plan.
Indications:
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QTc interval >470 msec in males and >480 msec in females
Documented history of Torsades de pointes
Presence of T-wave alternans AND notched T Waves in 3 leads
A first degree relative with a confirmed clinical diagnosis of LQTS
Members with a QTc>440 msec AND an episode of aborted sudden death
without another cause (such as cardiomyopathy or MI)
Unexplained syncope and either
 A QTc >450 msec for males or >460 msec for females OR
 A known family member (1st or 2nd degree relative) with genetically
identified LQTS
Limitations:
 Members with a known cause of acquired LQTS such as drug induced,
intracranial bleed or acute MI
 Genetic screening for LQTS in the general population
 Genetic screening to determine prognosis and/or direct therapy in patients
with known LQTS
 Family testing of members with genetically-proven LQTS
Molecular Susceptibility Testing for Breast Cancer and/or Ovarian (BRCA and
BART Testing):
In order to assess medical necessity for BRCA testing, adequate information must be
furnished by the treating physician. Necessary information includes, but is not limited to:
 Physician’s letter of medical necessity to include
o The physician’s evaluation of the member’s condition and
o Detailed personal and family history of Breast/Ovarian and other
pertinent cancers among first and second degree relatives (when
applicable)
o Additional information will be requested if necessary
o BART test- BRCA test results in addition to the above information
The Medical Management staff assigned to review obtains the clinical information
according to determine if there is adequate clinical information. If the case does not
meet established criteria, it is referred to a Medical Director. The Medical Director will
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 10 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
then determine if the request service is medically necessary and appropriate. The
Medical Management staff completes the review process and communicates the review
decision according to the Timeliness of UM Decisions policy for the member’s benefit
plan.
Indications for BRCA1/BRAC2 Test
BRCA testing is indicated in any ONE (1) of the following situations (1-8)
1. Family history with known BRCA1/BRCA2 mutation (male or female)
2. Personal history of breast cancer (including invasive and ductal carcinoma insitu
breast cancers) and at least ONE (1) of the following:
 Diagnosed age ≤ 45 years old
 Diagnosed age ≤ 50 years old
AND
o 1 close blood relative with breast cancer ≤ 50 years old
OR
o 1 close blood relative with epithelial ovarian cancer, fallopian cancer, or
primary peritoneal cancer
OR
o Limited family history
 2 breast primaries when first breast cancer diagnosis occurred prior to age 50(2
breast primaries include bilateral diseases or cases where there are 2 or more
separate ipsilateral primary tumors)
 Diagnosed age < 60 yrs with triple negative breast cancer (ER neg, PR neg, HER
neg)
 Diagnosed at any age
AND
o 2 close blood relatives with breast cancer or epithelial ovarian cancer,
fallopian tube cancer, or primary peritoneal cancer at any age
 Close male blood relative with breast cancer
 Personal history of epithelial ovarian cancer, fallopian tube cancer, or primary
peritoneal cancer
 Personal background of ethnicity that is associated with higher mutational
frequency (e.g. founder populations of Ashkenazi Jewish, Swedish, Icelandic,
Hungarian and Dutch)
 Note: Testing for founder mutation(s), if available, should be performed first. Full
sequencing may be considered if other HBOC criteria are met.
OR
3. Personal history of epithelial ovarian cancer, fallopian tube cancer, or primary
peritoneal cancer
OR
4. Personal history of male breast cancer
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 11 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
OR
5. Personal history of breast and/or ovarian cancer at any age
AND
 2 close blood relatives with pancreatic cancer at any age
OR
6. Personal history of pancreatic adenocarcinoma at any age
AND
 2 close blood relatives with breast and/or ovarian and/or pancreatic
cancer at any age
OR
7. Family history only
AND
 1st or 2nd degree relative who meets any of the above criteria (1-6)
OR
 3rd degree blood relative with breast cancer and/or ovarian/fallopian
tube/primary peritoneal cancer
AND
 2 close blood relatives with breast cancer (at least one with breast cancer
≤ 50yr and/or ovarian cancer (at least 1 with breast cancer 50 yr)
OR
8. Limited family history, such as fewer than 2- 1st or 2nd degree female relatives or
female relatives surviving beyond 45 year in either linage. Note: When investigating
limited family history, the maternal and paternal sides should be considered
separately.
Testing Family Members
Occasional, blood or tissue samples from other non-covered family members are
required to provide the medical information necessary for the proper medical care of a
member. Such molecular-based testing for BRCA and other specific heritable disorders
in non-members will be reviewed for medical necessity when ALL of the flowing
conditions are met:
1. The information is needed to adequately assess risk in the member
AND
2. The information will be used in the immediate care plan of the member
AND
3. The non-covered family member’s benefit plan (if any) will not cover the test
and the denial is based on specific plan exclusion.
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 12 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Indications for BRACAnalysis® Rearrangement Test (BART):
BART testing is indicated when the member is BRCA1/BRCA2 negative
AND
In any ONE (1) of the following situations (1-5)
1. Breast cancer before age 50
AND
 Family history of 2 or more close blood relatives with a diagnoses
of breast cancer before age 50 and/or ovarian cancer at any age
2. Ovarian cancer at any age
AND
 Family history of 2 or more close blood relatives with a diagnoses
of breast cancer before age 50 and/or ovarian cancer at any age
3. Male breast cancer at an age
AND
 Family history of 2 or more close blood relatives with a diagnoses
of breast cancer before age 50 and/or ovarian cancer at any age
4. Breast cancer at or after age 50 and ovarian cancer at any age
AND
 Family history of 1 or more close blood relatives with breast cancer
before age 50 and/or ovarian cancer at any age
5. Breast cancer before age 50 and ovarian cancer at any age
AND
 No additional relatives are required
Limitations of BRCA1/BRCA2 and BART testing
1. Experimental and Investigational and therefore not covered:
 BRCA testing for assessment of risk of cancers other than breast or
ovarian cancers
2. Not medically necessary and therefore not covered:
 Genetic testing in members less than 18 years old for BRCA1 and BRCA2
mutations
 When BRCA testing is performed primarily for medical management of
other family members that are not covered by UPMC Insurance Services
Division
3. Members post bone marrow transplant (allogenic or autologous) should not have
testing via blood or buccal samples (due to contamination of donor DNA). In
these cases, DNA should be extracted from a fibroblast culture.
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 13 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Genetic Testing for Inherited Colorectal Cancers: (HPNCC, FAP and MAP testing)
HPNCC indications:
UPMC Insurance utilizes modified Bethesda criteria to determine Medical necessity.
Individuals must meet one of the following for medical necessity of HPNCC testing.
 Diagnosed with colorectal cancer before the age of 50 years
 Presence of synchronous or metachronous colorectal or other HNPCC related
tumors regardless of age.
 Colorectal cancer with the MSI-H histology diagnosed in individual before the age
of 60 years.
 Individuals with colorectal cancer with one or more first-degree relatives with an
HNPCC related tumor, with one of the cancers diagnosed before age 50 years.
 Colorectal cancer diagnosed in two or more first or second degree relatives with
an HNPCC related tumor, regardless of age.
An alternative indication for who should have genetic testing is to perform the MSI-H
testing on colon cancer tissue of patients meeting any of the Bethesda modified criteria.
It the MSI-H is positive, the one could proceed with genetic testing for HNPCC.
Note: Genetic testing to determine the carrier status of the HNPCC gene may be
considered medically necessary in patients without a history of colorectal cancer but
who have a first- or second-degree relative with a known HNPCC mutation.
FAP indications:
 Members with greater than 100 colonic polyps identified by colonoscopy:
OR
 History of FAP in first degree relatives
 Individuals with 10-100 adenomas may be considered for APC testing.
MYH Associated Polyposis (MAP) indications:
 Individuals with personal history of adenomatous polyposis and a negative APC
test and a negative family history for adenomatous polyposis.
 Individual with a personal history of AP and family history for recessive
inheritance where only siblings are affected;
OR
 Asymptomatic siblings of individuals with know MYH polyposis
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 14 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Cystic Fibrosis Genetic Testing:
Indications:
 Diagnostic purpose
o A clinical presentation of CF and a negative/equivocal sweat test
o Infants with meconium ileus or other symptoms indicative of CF who are
too young to produce adequate amounts of sweat for a sweat chloride test
 Carrier Screening for any of the following
o Individuals with positive family history of CF
o Adults with partners with known CF mutation or family history of and
planning a pregnancy
o Woman’s reproductive partner had CF or apparently isolated congenital
bilateral absence of vas deferens
 Prenatal testing of fetus may be indicated for any of the following
o Embryo at risk when either a parent has a diagnosis of CF, is a known
carrier of a CFTR mutation of has a family history of CF
o Fetus with fetal echogenic bowel per ultrasound during 2 nd trimester
Limitations:
 Carrier screening in the general population
 If a patient has been previously testing, results should be documented and the
test not repeated
 Complete gene sequencing (beyond the ACMG-23 standard mutation panel) is
not appropriate for carrier screening because it may yield results that are difficult
to interpret, hence it is not covered and requests for exceptions will be reviewed
on a case by case basis.
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 15 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Cigna Requirements
Genetic Disease Screening Panels: Cigna covers genetic testing for specific diseases
and disorders as medically necessary when established criteria for that specific
genetically transmitted disease are met. For specific criteria, please refer to the
following related disease specific indications and limitations.
CPT Code: Cystic Fibrosis Testing
81220 CFTR Gene Analysis Common
81221 CFTR Known Familial Variant
81223 CFTR Full Gene Sequence (NOT COVERED)
CPT Code: Hemochromatosis
82156 Hemochromatosis HFE Gene Analysis
CPT Code: Hereditary Hypercoagulability
81241 Factor V Leiden Variant
81240 Prothrombin G20210A Gene Analysis
81479 Unlisted Molecular Pathology Procedure (NOT COVERED)
CPT Code: Hemoglobin Molecular consisting of:
81257 HBA1/HBA2 Gene Analysis Common Variant
81401 Molecular Procedure Level 2
81403 Molecular Procedure Level 4
81404 Molecular Procedure Level 5
CPT Code: Long QT Syndrome
81280 Long QT Syndrome Gene Analysis, full sequence
81281 Long QT Syndrome Gene Analysis, known familial sequence variant
81282 Long QT Syndrome Gene Analysis, duplication/deletion variants
CPT Code: Breast Cancer and Ovarian Cancer Testing
81211 BRCA1/BRCA2 Gene Analysis Common Variant
81212 BRCA1/BRCA2 185/5385/6174 Variants
81213 BRCA1/BRCA2 Uncommon Variant
81214 BRCA1 Gene Analysis Common Variant
81215 BRCA1 Known Familial Variant
81216 BRCA2 Gene Analysis Common Variant
81217 BRCA2 Known Familial Variant
BRACAnalysis® Rearrangement Test (BART)(Myriad Genetic
Laboratories, Inc., Salt Lake City, UT)
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 16 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
CPT Code: TPMT Genotyping
81401 Molecular Procedure Level 2
Cystic Fibrosis:
Cigna covers genetic testing for cystic fibrosis (CF) using the American College of
Medical Genetics (ACMG) mutation core panel (ACMG-23) as medically necessary of
any of the following:
o Confirmatory testing
 Exhibition of symptoms of CF but has a negative sweat test
 Infant with other symptoms of CF but is too young to produce
adequate volumes for sweat test.
 Infant with an elevated immunoreactive tyrpsinogen(IRT) with no
suspicion of CF
o Preconception or prenatal carrier testing of an individual who is pregnant
or a prospective biologic parent
o Prenatal testing of fetus (amniocentesis or chorionic villus sampling)
 Parent has a diagnosis of CF or a known carrier of mutation
 Fetal echogenic bowl has been identified on ultrasound
ICD-9-CM Diagnosis Codes:
277.00 CF without mention of meconium ileus
277.01 CF with mention of meconium ileus
277.02 CF with pulmonary manifestations
277.03 CF with gastrointestinal manifestations
277.09 CF with other manifestations
V82.71 Screening for genetic disease carrier status
Cigna Does Not Cover for:
o Carrier Screening in general population
o Routine genetic mutation screening in newborns
o Extended mutation panels
o CPT: 81223 CFTR Full Gene Sequence
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 17 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Genetic Testing for Hereditary Hemochromatosis: Cigna covers genetic testing to
confirm a diagnosis of HFE-HHC as medically necessary without a requirement for preand post-test genetic counseling when an individual has findings consistent with
hemochromatosis and a serum transferrin iron saturation greater than or equal to 45%,
but the diagnosis remains uncertain after completion of conventional testing.
ICD-9-CM Diagnosis Code: 275.01 Hereditary hemochromatosis
Genetic Testing for Hereditary Hypercoagulability Disorders:
Cigna covers genetic testing with targeted mutation analysis for coagulation Factor V
Leiden and coagulation factor II (20210G) as medically necessary for either of the
following indications:
o Confirmatory testing in ANY Of the following situations
 Age <50 with history of unexplained venous thrombosis
 Age <50 with unexplained arterial thrombosis in the absence of
other risk factors for atherosclerotic vascular disease
 Venous thrombosis in an unusual site
 Recurrent venous thrombosis
 Venous thrombosis and a strong family history of thrombotic
disease
 Venous thrombosis in a pregnant woman or a woman taking oral
contraceptives
 MI in female smoker age <50
 Predictive testing in a woman of childbearing age with intent/ability
to conceive who has first-degree relative with history of high-risk
thrombophilia
ICD-9-CM Diagnosis Codes:
2869
Other and unspecified coagulation defects
28981
Primary hypercoagulable state
410.00-410.92 Acute Myocardial Infarction
444.0-444.9 Arterial embolism and thrombosis
452
Portal vein thrombosis
453.0-453.9 Other venous embolism and thrombosis
557.0
Acute vascular insufficiency of intestine
634.00-634.92 Spontaneous abortion
646.30
Habitual aborter, unspecified as to episode of care or not applicable
646.33
Habitual aborter, antepartum condition or complication
671.50-671.54 Other phlebitis and thrombosis in pregnancy and the puerperium
V12.51
Personal history of venous thrombosis and embolism
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 18 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Cigna DOES NOT COVER for the following indications because they are not
considered medically necessary:
o General population screening
o Routine screening during pregnancy or prior to the use of oral
contraceptives, HRT or SERMs
o Newborn or routine testing on asymptomatic child
o Routine initial testing in an individual with arterial thrombosis
o Adverse pregnancy outcomes such as recurrent pregnancy loss,
preeclampsia, intrauterine growth restriction or placental abruption
o Testing of an asymptomatic first-degree relative of an individual with
proven symptomatic thromboembolism and a proven factor V Leiden of
factor II mutations for the purpose of considering primary prophylactic
anticoagulation
o Prenatal testing of fetus
Cigna DOES NOT COVER genetic testing for ANY of the following indications because
it is considered experimental, investigational or unproven:
o F2 (coagulation factor II) 1199G<A Variant
o F5 (coagulation factor V) HR2 Variant
o F7 (coagulation factor VII) R353Q Variant
o F13B (factor XIII, B polypeptide), V34L variant
ICD-9-CM Diagnosis Codes: Not covered
V78.8
Special Screening for other disorders of blood and blood-forming
organs
V78.9
Special screening for unspecified disorder of blood and blood
forming organs
V82.71
Screening for genetic disease carrier status
V82.79
Other genetic screening
2869
Other and unspecified coagulation defects
28981
Primary hypercoagulable state
410.00-410.92 Acute Myocardial Infarction
444.0-444.9 Arterial embolism and thrombosis
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 19 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Genetic Testing for Hemoglobinopathies:
Cigna covers genetic testing for hemoglobinopathies (i.e. thalassmemias and sickle cell
disease) as medically necessary for ANY of the following indications:
o Confirmatory testing with targeted mutation analysis for common deletions
or variants in gene HBB, HBA1 or HBA2 in the following situation
 Symptomatic individual with clinical features suggestive of a
hemoglobinopathy, results by conventional studies yield equivocal
results and a definitive diagnosis remains uncertain
 Infant with a newborn screening test positive for hemoglobinopathy
o Confirmatory testing with sequence analysis when targeted mutation
analysis is negative and the clinical suspicion of hemoglobinopathy
remains high
o Preconception or prenatal genetic testing to determine carrier status of a
prospective biological parent with the capacity and desire to reproduce
when ANY of the following applies
 An affected family member (first- or second-degree relative) who
has thalassemia or sickle cell disease
 The individual is the reproductive partner of a known carrier
 The individual is of African, Asian, Mediterranean, Middle Easter or
Caribbean descent and result of testing by conventional studies
yield equivocal results and a definitive diagnosis remains uncertain
o Prenatal testing of a fetus in either of the following situations:
 Testing targeted mutational analysis of the known mutation when
both parents are known carriers for the disorder
 One parent is a known carrier and the mutation status of the other
parent is not known and can’t be determined
ICD-9-CM:
282.41-282.49 Thalassemias
282.5
Sickle Cell Trait
282.60-282.69 Sickle Cell Disease
282.7
Other hemoglobinopathies
V18.9
Family history of genetic disease carrier
V82.71
Screening for genetic disease carrier status
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 20 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Genetic Testing for Long QT Syndrome (LQTS):
Cigna covers genetic testing for the long QT syndrome as medically necessary for ANY
of the following indications:
o Confirmatory testing with full sequent analysis when there is confirmed
prolonged QT interval on electrocardiogram or Holter monitor and an
acquired cause has been ruled out
o Predictive testing with full sequence analysis when there is evidence in a
first-degree relative of a history of prolonged QT interval on ECG or Holter
monitor , sudden death or near sudden death and a genetic syndrome is
suspected
o Predictive testing for the known familial sequence variant when there is a
positive genetic test for LQTS in a first-degree relative.
o Prenatal testing of a fetus for known familial sequence variant when the
disease-causing mutation has been identified in an affected biologic
parent
o
Cigna covers genetic testing for LQTS with deletion and duplication analysis as
medically necessary when sequence analysis is negative and the clinical suspicion of
LQTS remains high.
Cigna DOES NOT COVER genetic screening for LQTS if the general population,
because such screening is considered not medically necessary or of unproven benefit.
ICD-9-CM:
426.82
Long QT Syndrome
427.0-427.69 Cardiac Dysrhythmias
780.2
Syncope and collapse
780.4
Dizziness and giddiness
V12.53
Personal history of sudden cardiac arrest
V17.41
Family history of sudden cardiac death (SCD)
V17.49
Family history of other cardiovascular diseases
V18.9
Family history of genetic disease carrier
Not covered: V82.79
Other genetic screening
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 21 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Genetic Testing for Susceptibility to Breast and Ovarian Cancer (BRCA1 and
BRCA2):
Cigna covers BRCA1 and BRCA2 genetic testing for susceptibility to breast or ovarian
cancer in adults as medically necessary for ANY of the following indications:
o Biologically-related individual from a family with a known BRCA1 or
BRCA2 mutation
o Personal history of breast cancer and ANY of the following:
 Diagnosed at age 45 or younger
 Diagnosed at age 50 or younger with EITHER of the following:
 At least one close blood relative with breast cancer at age 50

o
o
o
o
o
or less
At least one close blood relative with epithelial ovarian,
fallopian tube or primary peritoneal cancer
 Diagnosed with two breast primaries (includes bilateral disease or
cases where there are two or more clearly separate ipsilateral
primary tumors) when the first breast cancer diagnosis occurred
prior to age 50
 Diagnoses at age 60 or younger with a triple negative breast cancer
 Diagnosed at age 50 or younger with a limited family history
 Diagnosed at any age and there are at least two close blood
relatives with breast cancer or epithelial ovarian, fallopian tube or
primary peritoneal cancer at any age
 Close male blood relative with breast cancer
 Personal history of epithelial ovarian, fallopian tube or primary
peritoneal cancer
Personal history of epithelial ovarian fallopian tube or primary peritoneal
cancer
Personal history of male breast cancer
Personal history of breast, ovarian or pancreatic cancer at any age with
two or more close blood relatives with breast, ovarian or pancreatic cancer
at any age
No personal history of breast or ovarian cancer and a family history of
first- or second-degree blood relative meeting any of the above criteria
No personal history of breast or ovarian cancer and a family history of a
third-degree blood relative with breast and/or epithelial ovarian/fallopian
tube/primary peritoneal cancer with two or more close blood relatives with
breast and/or ovarian cancer
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 22 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Cigna covers BRACAnalysis® Rearrangement Test (BART)(Myriad Genetic
Laboratories, Inc., Salt Lake City, UT) as medically necessary when conventional
BRCA1/BRAC2 testing is negative and for ANY of the following indication:
o Breast Cancer diagnosed before age 50 and a family history of EITHER of
the following or
o Ovarian Cancer diagnosed at an age and a family history of EITHER of
the following or
o Male breast cancer diagnosed at any age and a family history of EITHER
of the following or
o Breast cancer diagnosed at or after age 50 and ovarian cancer at an age
and a family history of EITHER of the following
 Two or more diagnoses of breast cancer before age 50 (male
breast at any age)
 Ovarian cancer at any age
o Diagnosed with both breast cancer before age 50 and ovarian cancer at
any age
Cigna DOES NOT COVER BRCA1/BRCA2 genetic testing for susceptibility to breast
cancer for the following because it is not considered medically necessary:
o Genetic screening for general population
o Testing of individuals with no personal history of breast or ovarian cancer
except as noted above
o Testing of individuals under 18 years of age
Cigna DOES NOT COVER other genetic tests for susceptibility to breast and ovarian
cancer because they are considered experimental, investigational or unproven.
(e.g.Candidate breast cancer susceptibility genes and single nucleotide polymorphisms
(SNPs)
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 23 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
ICD-9-CM Diagnosis Codes:
158.8
Malignant neoplasm of specified parts of peritoneum
158.9
Malignant neoplasm of peritoneum, unspecified
174.0-174.9 Malignant neoplasm of female breast
175.0-175.9 Malignant neoplasm of male breast
183.0
Malignant neoplasm of ovary
198.6
Secondary malignant neoplasm of ovary
198.81
Secondary malignant neoplasm of breast
233.0
Carcinoma in situ of breast
238.3
Neoplasm of uncertain behavior of breast
V10.3
Personal history of malignant neoplasm of breast
V10.41
Personal history of malignant neoplasm of cervix uteri
V10.43
Personal history of malignant neoplasm of ovary
V10.44
Personal history of malignant neoplasm of other female genital organs
V10.88
Personal history of malignant neoplasm of other endocrine glands
and related structures
V16.0
Family history of malignant neoplasm of gastrointestinal tract
V16.3
Family history of malignant neoplasm, breast
V16.41
Family history of malignant neoplasm, ovary
V84.01
Genetic susceptibility to malignant neoplasm of breast
V84.02
Genetic susceptibility to malignant neoplasm of ovary
Not medically covered: V82.79 Other genetic screening
Genotyping for Thiopurine Methyltranferase (TPMT) Deficiency in Individuals with
Inflammatory Bowel Disease (IBD):
Cigna covers genotyping for thiopurine methyltransferase (TPMT) deficiency as
medically necessary for the management of inflammatory bowel disease (IBD) for either
of the following:
o Prior to the initiation of azathioprine (AZA) or 6-mercaptopurine (6-MP)
therapy
o When standard dosing of AZA/6-MP fails to produce a therapeutic
response
ICD-9-CM Diagnosis Codes:
555.0-555.9 Regional enteritis, Crohn’s disease
556.0-556.9 Ulcerative colitis
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 24 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Gateway Health Plan Requirements
Gateway has contracted with many participating hospitals and laboratory facilities for
outpatient laboratory services. Gateway members are required to have all of their
outpatient laboratory work completed through the appropriate contracted lab. Currently
IRMC Lab is not a contracted laboratory with Gateway Medicaid or Medicare Assured.
If IRMC is designated as a lab for any reason please contact Provider Services at 1800-685-5205 for further explanation of what services require an authorization.
Authorizations are the responsibility of the ordering provider.
STAT laboratory services must only be utilized in urgent cases. If a lab other than the
member’s designated lab is to be used, a referral form is required. Every effort should
be made to direct the member to his/her designated lab.
Unusual circumstances arise where it is impossible to follow the laboratory procedures
outlined above, please contact Gateway’s Utilization Management Dept at 1-800-3921146 for assistance.
AETNA Requirements
Aetna requires precertification for the following genetic testing:
BRCA Genetic Testing: 1-877-794-8720
CPT Codes:
81211
BRCA1/BRCA2 Gene Analysis Common Variant
81212
BRCA1/BRCA2 185/5385/6174 Variants
81213
BRCA1/BRCA2 Uncommon Variant
81214
BRCA1 Gene Analysis Common Variants
81215
BRCA1 Known Familial Variant
81216
BRCA2 Gene Analysis Common Variants
81217
BRCA2 Known Familial Variant
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 25 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
Maternity genetic testing through the Beginning Right® Maternity Program: 1-800272-3531
CPT Code: Hemoglobin Molecular consisting of:
81257 HBA1/HBA2 Gene Analysis Common Variant
81401 Molecular Procedure Level 2
81403 Molecular Procedure Level 4
81404 Molecular Procedure Level 5
CPT Codes:
81280 Long QT Syndrome Gene Analysis, full sequence
81281 Long QT Syndrome Gene Analysis, known familial sequence variant
81282 Long QT Syndrome Gene Analysis, duplication/deletion variants
CPT Codes:
81220 CFTR Gene Analysis Common Variants
81221 CFTR Known Familial Variant
Pre-implantation genetic testing: 1-800-575-5999
Medicare Requirements
Medicare states genetic testing will be covered if medical necessity is met.
FirstCare PPO
The services requiring preauthorization include, but are not limited to, those services
listed below. This listing is subject to change. Please contact customer service 1-800240-3270 (Commercial) or 1-800-249-7366 (Self-funded) for information on the most
up-to-date listing. Payments will be reduced for covered services if a pre-authorization
form is not completed.
Genetic Testing of any type- Excludes prenatal genetic testing
HealthAmerica Coventry
Genetic studies are listed as possibly needing prior authorization, but no specific testing
is listed. For specific authorization information, use the Authorization Procedure Code
Lookup at www.DirectProvider.com or contact Customer Service at 1-800-735-4404
(Western PA) or 1-800-290-0190 (Advantra). Coverage is subject to all plan provisions,
limitations and eligibility.
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 26 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
CPT Information:
DESCRIPTION
BCR/ABL1 Major BREAK QUAL/QUANT
BCR/ABL1 Min Break Qual/Quant
BCR/ABL1 Other BREAK QUAL/QUANT
BRAF Gene Analysis V600e Variant
BRCA1/BRCA2 GENE Analysis Common
VARIANT
BRCA1/BRCA2 185/5385/6174 Variants
BRCA1/BRCA2 Uncommon Variant
BRCA1 Gene Analysis Common Variants
BRCA1 Known Familial Variant
BRCA2 Gene Analysis Common Variants
BRCA2 Known Familial Variant
CFTR Gene Analysis Common Variants
CFTR Known Familial Variant
CFTR Dup/Del Variants
CFTR Full Gene Sequence
CFTR Intron 8 Poly-T Analy
EGFR Gene Analysis Common Variant
PROTHROMBIN G20210A Gene Analysis
FACTOR V LEIDEN Variant Gene Analysis
HEMOCHROMATOSIS HFE Gene Analysis
HBA1/HBA2 Gene Analysis Common Variant
JAK2 Gene Analysis V617F Variant
KRAS Gene Analysis Codon 12/13 Variant
MTHFR Gene Analysis Common Variant
SERPIN PEPTIDASE INHIB Gene Analysis
HLA ONE LOCUS DQA1/DQB1
Molecular Procedure Level 2
Molecular Procedure Level 3
Molecular Procedure Level 4
Molecular Procedure Level 5
Unlisted Molecular Path Procedure
CMV Gene Analysis By Nucleic Acid
HBV Gene Analysis By Nucleic Acid
MCR ALT
CODE/CPT
81206
81207
81208
81210
81211
81212
81213
81214
81215
81216
81217
81220
81221
81222
81223
81224
81235
81240
81241
81256
81257
81270
81275
81291
81332
81376
81401
81402
81403
81404
81479
87910
87912
IRMC LIS code
BCRABLFISH
BRAF
CYSFIB
EGFR
PTGENE
F5MUT
HEMOCHROMA
JAK2
KRAS
MTHFR
in A1APHENO
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 27 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
DESCRIPTION
Pancreatitis Mutation
Molecular Procedure Level 4
HGB Molecular
HBA1/HBA2 Gene Analysis Common Variant
Molecular Procedure Level 2
Molecular Procedure Level 4
Molecular Procedure Level 5
Chrons Prognostic
Immunoassay Quant #1
Immunoassay Quant #2
Transglutaminase Antibody
ASIALOGM1 IGG
ASIALOGM1 IGM
GD1A IGG
Immunofluorescent Indirect
Molecular Procedure Level 2
TPMT Genotyping
Molecular Procedure Level 2
REVISED:
MCR ALT
CODE/CPT IRMC LIS code
HERPANMUT
81403
81257
81401
81403
81404
CROHNPROG
83520
83520
88347
83520
83520 91
83520 91
88347
81401
TPMTGENO
81401
SUBJECT:
GENETIC TESTING REQUIREMENTS
REFERENCE # GL100-1
PAGE: Page 28 of 28
DEPARTMENT: DEPARTMENT OF LABORATORY MEDICINE
EFFECTIVE: 4/1/2013
APPROVED BY:
REVISED:
REFERENCES:
Aetna Participating Provider Precertification List; 23.03.858.1P,Effective 1/1/13
Aetna Medical Precertification List, www.aetna.com/healthcare-professionals/policiesguidelines/precertification _policy, Obtained 2/4/13
Cigna Medical Coverage Policy Number 0280: Genetic Disease Screening Panels
Effective Date 2/15/12
Cigna Medical Coverage Policy Number 0022: Genetic Testing for Cystic Fibrosis,
Effective Date 1/15/13
Cigna Medical Coverage Policy Number 0255: Genetic Testing for Hereditary
Hypercoagulability Disorders, Effective Date 12/15/12
Cigna Medical Coverage Policy Number 0192: Genetic Testing for
Hemoglobinopathies,Effective Date 9/15/12
Cigna Medical Coverage Policy Number 0193: Genetic Testing for Long QT Syndrome
(LQTS), Effective Date 10/15/12
Cigna Medical Coverage Policy Number 0001: Genetic Testing for Susceptibility to
Breast and Ovarian Cancer (e.g.BRCA1 & BRAC2), Effective Date 3/15/12
Cigna Medical Coverage Policy Number 0003: Genotyping for Thiopurine
Methyltransferase (TPMT) Deficiency in Individuals with Inflammatory Bowel Disease
(IBD), Effective Date 1/15/13
FirstCare PPO Services Requiring Pre-Authorization
Gateway Health Plan®, Laboratory Services, 2012 Medicaid Provider Office Policy and
Procedure Manual pp 51-52.
Coventry HealthAmerica/Advantra; Prior Authorization List
Highmark Medical Policy Bulleting, Section Laboratory, Number L-34, Genetic Testing,
Effective date 1/1/2013
Highmark Special Bulletin for Network Providers,”Highmark to Update Its List of
Outpatient Procedures/Services Requiring Authorization” Rev 10/12.
Highmark’s List of Procedures/DME Requiring Authorization Rev. 10/12
Medicare National Coverage Determinations Manual, Chapter 1, Part 3 (Sections 170190.34) Coverage Determinations Rev. 131, 2-23-11
UPMC Healthplan Physician Partner Update Technology Assessment Committee
4/2012
UPMC Healthplan Quick Reference Guide Effective 2/1/2013
UPMC Healthplan Policy:PAY.080, 3/2012 Genetic Testing
UPMC Healthplan Policy:PAY.116, 6/2012 Genetic Testing for Cystic Fibrosis
UPMC Healthplan Policy:PAY.042, Rev 8/12 Genetic Testing for Inherited Colorectal
Cancers
UPMC Healthplan Policy:MP.055, Rev 7/2012 Molecular Susceptibility Testing for
Breast Cancer and/or Ovarian Cancer (BRCA and BART Testing)
UPMC Healthplan Policy: MP.027, Rev 5/2012 Genetic Testing for Long QT Syndrome