Genetic testing

Doctor looking through microscope

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 Policy Policy number Policy type Authorization Required Genetic Counseling Required
Whole Exome and Whole Genome Sequencing MP9548 General X X
General Genetic Testing Policy MP9012 General Some  
Hereditary Cardiac Disease and Arrhythmias  MP9472 Cancer X X
Thrombophilia  MP9473 General    
Reproductive Carrier Screening and Prenatal Diagnosis  MP9477 Maternal-fetal Some  
BRCA1 and BRCA2  MP9478 Cancer X X
Pharmacogenetic Testing  MP9479 General X  
Polyposis  MP9482 Cancer X X
Multiple Endocrine Neoplasia, Type 1 & 2  MP9483 Cancer X X
Diffuse Gastric Cancer – CDH1 Gene  MP9484 Cancer X X
Somatic Tumor Markers, Gene Expression Assays for Hematology/Oncology Indications  MP9486 General    
Lynch Syndrome  MP9487 Cancer X X
Cowden Syndrome – PTEN Gene  MP9488 Cancer X X
Chromosomal Microarray Analysis  MP9491 General    
Neurologic Disorders  MP9497 General X X
Stickler Syndrome MP9504 General X X
Marfan Syndrome  MP9506 General X X
Ehlers-Danlos Syndrome  MP9505 General X X
Maturity onset of the young (MODY) sequencing panel  MP9507 General X X
Hereditary Cancer Susceptibility  MP9521 Cancer    
Hereditary Hemorrhagic Telangiectasia (HHT)  MP9524 General X X
Hypercholesterolemia  MP9525 General X X
Birt Hogg Dube Syndrome  MP9527 General X X
Focal Segmental Glomerular Sclerosis  MP9543 General X X

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