Genetic Counseling
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This policy governs when genetic counseling is considered medically necessary for Aetna members, primarily in pregnancy management and in conjunction with medically necessary genetic testing, and identifies indications considered experimental or investigational.
No material clinical or coverage changes in this revision.
Coverage Criteria for Genetic Counseling
Genetic counseling — pregnancy management (Medically Necessary)
Covered when ANY ONE of the following pregnancy-related indications is present:
Any single listed indication qualifies (policy uses OR logic).
Genetic counseling — non-pregnancy (Medically Necessary)
Covered when provided in consideration of, or in conjunction with, medically necessary genetic testing and consistent with ACMG guidelines.
Both conditions must be met.
Experimental and Investigational (Not Covered)
Not covered when the indication is not among the listed ones:
Services for indications not listed in the medical necessity section are not covered.
Genetic counseling services provided for pregnancy management may not be covered if the member's benefit plan explicitly excludes family planning benefits. Providers should verify the member's specific benefit plan description before billing or scheduling services, as coverage for pregnancy-related counseling is dependent on plan provisions.
Genetic counseling for indications that are not listed in the policy is considered experimental and investigational and therefore not medically necessary. Coverage is limited to the specified indications; services for other reasons may be denied because effectiveness for those indications has not been established.
Specific Indications and Scenarios
Pregnancy-related risk factors and scenarios listed in the policy
Each item alone qualifies under the pregnancy management criteria.
Genetic counseling in conjunction with medically necessary genetic testing per ACMG guidelines
Counseling must be tied to medically necessary testing and follow ACMG guidance to be considered medically necessary.
Billing and Diagnosis Codes
| 96040 | Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family |
| S0265 | Genetic counseling, under physician supervision, each 15 minutes |
| 82106 | Alpha-fetoprotein (AFP); amniotic fluid |
| C18.0-C18.9 | Malignant neoplasm of colon |
| D45 | Polycythemia vera |
| D57.00-D57.819 | Sickle-cell disorders |
| E28.39 | Other primary ovarian failure |
| E28.8 | Other ovarian dysfunction |
| E30.0-E30.1 | Delay in sexual development and puberty and precocious sexual development and puberty |
| E75.02 | Tay-Sachs disease |
| E84.0-E84.9 | Cystic fibrosis |
| F70-F79 | Mental retardation |
| F84.0 | Autistic disorder |
Provider Actions, Documentation, and Billing Guidance
Coverage tied to selection criteria (96040, S0265, related lab codes)
CPT 96040 and HCPCS S0265 (and related listed lab codes such as 82106) are covered only when the policy's selection criteria for genetic counseling are met; coverage depends on meeting the medical necessity indications listed in this bulletin.
- 96040 — Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family (covered if selection criteria are met).
- S0265 — Genetic counseling, under physician supervision, each 15 minutes (covered if selection criteria are met).
- 82106 — Alpha-fetoprotein (AFP); amniotic fluid (related lab code listed).
Prior authorization determined by plan
Prior authorization requirements are not set by this bulletin; participating providers must follow the member's plan benefit provisions and program rules to determine if prior authorization is required.
- This Clinical Policy Bulletin is guidance to assist in administering plan benefits but does not define prior authorization—check the member's plan.
- Prior authorization requirements are determined by the member's plan and program provisions.
Step therapy — none specified
No step therapy requirements are specified in this Clinical Policy Bulletin for genetic counseling services.
- Providers should consult plan-specific provisions if unsure, but the bulletin itself lists no step therapy rules.
Informed consent and counseling documentation
Obtain informed consent and document counseling that the genetic test might reveal carrier status or disease-state information that could affect health, insurance, career, marriage, or reproductive options.
- Documentation should reflect that the patient was informed of potential implications and the individual's right to accept or refuse testing per ACMG guidance.
Policy and documentation note
Policy history and review dates are maintained in the bulletin; providers should consult plan-specific Clinical Policy Bulletins and program provisions for details on documentation and benefit determinations.
- Last review: 03/28/2023; Effective: 11/19/1997; Next review: 02/08/2024.
- Clinical Policy Bulletins are guidance documents and do not constitute a contract—verify plan-specific requirements.
Denial risk — experimental/investigational indications
Genetic counseling for indications other than those listed in the medical necessity section is considered experimental and investigational and may be denied.
- The bulletin states effectiveness for indications other than the listed ones has not been established, and such services are not covered.
Coverage risk — subject to plan provisions
Coverage is subject to the member's plan provisions and program terms; the Clinical Policy Bulletin is intended to assist administration of benefits but does not guarantee coverage.
- Lack of adherence to plan provisions or program rules may result in denial of coverage.
Pre-test informed consent and ACMG-consistent counseling
Provide pre-test informed consent and counseling consistent with ACMG guidance, including discussion that testing may reveal carrier status or disease-state information and the implications for the individual's privacy, insurance, and reproductive options.
- Counseling should evaluate family risks, explain inheritance patterns, and allow informed decision-making about testing per ACMG recommendations.
Provider qualifications implied by counseling codes
Procedure codes for genetic counseling (96040, S0265) reflect services typically provided by qualified professionals (e.g., medical geneticists or genetic counselors); the policy references professional guidance though it does not mandate specific provider credentialing in this section.
- 96040 — Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family.
- S0265 — Genetic counseling, under physician supervision, each 15 minutes.
Information — consult policy for details
This bulletin provides policy guidance on genetic counseling indications, coding, and documentation; consult the bulletin and plan materials for specifics.
- The document lists covered indications, exclusions, and related codes—use the bulletin and plan benefit descriptions to confirm applicability.
Eligibility Requirements
Eligibility for genetic counseling includes a documented family history indicating risk factors such as family history of primary malignant neoplasm, known carrier status (e.g., Z14.1, Z14.8, Z84.81), and family history of congenital malformations or other relevant disorders (e.g., Z82.71, Z82.79, Z84.3). Use the corresponding ICD-10 codes from the policy when submitting claims to demonstrate that the member meets the family-history–based eligibility criteria.
Pre-test counseling should follow professional guidance and include documented informed consent that explains potential outcomes of testing, including carrier or disease-state findings and their implications for health, insurance, and reproductive decision-making. When counseling accompanies genetic testing, documentation of the counseling session and consent is expected in the medical record per ACMG/NSGC guidance.
Not Covered Services
Genetic counseling provided for indications other than those specifically listed in the medical necessity section is classified as experimental and investigational and is therefore not covered. This includes standalone counseling requests that are unrelated to the enumerated pregnancy indications or to medically necessary genetic testing consistent with ACMG guidelines.
Definitions
Background
Genetic counseling is a communication process between patients and trained professionals intended to provide information about genetic disease or risk, including inheritance, management, and reproductive options. Counseling should include discussion of implications for the individual and family and informed consent given the potential impact on health, insurance, and reproductive choices.
Revision History
Policy became effective.
Policy last reviewed on 03/28/2023.
Next scheduled review date set for 02/08/2024.
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