Policy details

  • Current Medical Policy MP9012 serves 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.

  • If you use the WellFirst Health Provider Portal, submit prior authorization requests via the provider portal. 
  • If you do not have access to submit prior authorization via the provider portal, fax the genetic testing prior authorization form to the number indicated on the form. 
Certain tests require pre-test and post- test genetic counseling. Prior authorization is not required for referrals to a genetic counselor.
 
THE CHART BELOW IDENTIFIES NEW MEDICAL POLICY COMPONENTS, WHICH MAY VARY BY TEST. SEE INDIVIDUAL POLICY FOR DETAILS
Medical PolicyPolicy numberPolicy typeAuthorization RequiredGenetic Counseling Required
Whole Exome and Whole Genome SequencingMP9548GeneralXX
General Genetic Testing PolicyMP9012GeneralSome 
Hereditary Cardiac Disease and ArrhythmiasMP9472CancerXX
ThrombophiliaMP9473General  
Reproductive Carrier Screening and Prenatal DiagnosisMP9477Maternal-fetalSome 
BRCA1 and BRCA2MP9478CancerXX
Pharmacogenetic TestingMP9479GeneralX 
PolyposisMP9482CancerXX
Multiple Endocrine Neoplasia, Type 1 & 2MP9483CancerXX
Diffuse Gastric Cancer – CDH1 GeneMP9484CancerXX
Somatic Tumor Markers, Gene Expression Assays for Hematology/Oncology IndicationsMP9486General  
Lynch SyndromeMP9487CancerXX
Cowden Syndrome – PTEN GeneMP9488CancerXX
Chromosomal Microarray AnalysisMP9491General  
Neurologic DisordersMP9497GeneralXX
Stickler SyndromeMP9504GeneralXX
Marfan SyndromeMP9506GeneralXX
Ehlers-Danlos SyndromeMP9505GeneralXX
Maturity onset of the young (MODY) sequencing panelMP9507GeneralXX
Hereditary Cancer SusceptibilityMP9521Cancer  
Hereditary Hemorrhagic Telangiectasia (HHT)MP9524GeneralXX
HypercholesterolemiaMP9525GeneralXX
Birt Hogg Dube SyndromeMP9527GeneralXX
Focal Segmental Glomerular SclerosisMP9543GeneralXX


See covered genetic testing that does not require prior authorization.

All of the above numbered medical policies meet the medical necessity criteria component.

See our full list of genetic testing policies. 

Additional Resources