Prior authorization required

Prior authorization is required for genetic testing; testing is covered only when results will change clinical management. Medicare referrals should follow the referenced Local Coverage Determination (LCD L36370).

• Testing must be clinically indicated — results must be expected to change management

Relevant CPT / panel codes

Use the CPT/Panel codes listed in the policy when requesting authorization or submitting claims; examples include single-gene and panel codes such as 81201, 81202, 81294–81301, 81317–81319, 81401, 81406, 81435, and 81436. Prior authorization may be required per payer practice for these tests.

• Examples: 81201, 81202, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81401, 81406, 81435, 81436

Genetic counseling visits covered for specified histories

One pre-test genetic counseling visit and one post-test genetic counseling visit are covered for members with family history of FAP, known APC mutation, Lynch syndrome–associated cancer, or a personal history of features of FAP or Lynch syndromes; document these visits when submitting for coverage.

• Cover one pre-test and one post-test genetic counseling visit for the listed family/personal history indications

Order testing per clinical guidelines

Policy references clinical practice guidelines (e.g., NCCN, ASCO) for appropriate ordering of genetic testing; follow guideline-based indications when requesting authorization.

• Order tests consistent with cited guidelines to support medical necessity

Document need for repeat testing

Requests for repeat genetic testing must include documentation demonstrating medical need (examples: recurrence of disease or a change in disease behavior); testing for colon cancer risk is considered a once‑in‑a‑lifetime test unless justified.

• Repeat testing requires clear documentation of need (e.g., disease recurrence or change in behavior)
• Policy states testing is once in a lifetime unless justified

Justify repeat test requests

Include a clear clinical justification when requesting repeat testing — for example, documented recurrence of disease or a change in disease behavior that would alter management.

• Justification must be specific and linked to management change to be considered medically necessary

Require pretest genetic counseling documentation for carrier testing

For carrier-status testing, include documentation of pretest genetic counseling; absence of pretest counseling documentation is listed as not medically necessary.

• Pretest genetic counseling documentation must be present when submitting carrier status testing requests

Prior authorization and medical necessity — denial risk

Prior authorization is required and testing is covered only when results will change clinical management; tests that do not meet covered indications or are listed as not medically necessary may be denied.

• Ensure indication meets the policy’s covered criteria to avoid denial

Denial risk for undocumented repeat testing

Requests for repeat testing that lack clear documentation of clinical need (e.g., recurrence or change in disease behavior) may be denied.

• Provide explicit clinical documentation to support repeat testing requests

Laboratory certification required (CLIA & CAP)

Testing must be performed in laboratories with CLIA and CAP certifications; tests performed in laboratories lacking these certifications risk denial.

• Verify the performing laboratory has CLIA and CAP certification before submitting claims or authorization requests

Document genetic counseling visits for covered indications

Document pre-test and post-test genetic counseling visits when applicable; one pre-test and one post-test counseling visit are covered for family history of FAP, APC mutation, Lynch syndrome–associated cancer, or personal history of syndrome features.

• Document counseling encounters in the medical record and include them in the authorization/claim documentation

Pretest counseling required for carrier testing (duplicate)

Pretest genetic counseling documentation is required for carrier-status testing; absence of documentation is listed as not medically necessary and may result in denial.

• Include evidence of counseling in requests for carrier testing

Pretest counseling required (duplicate)

Pretest genetic counseling documentation is required for carrier-status testing; ensure counseling is documented before requesting coverage.

• Failure to document pretest counseling is a listed not‑medically‑necessary condition

Prior authorization and expected genetic counseling

Prior authorization is required; genetic counseling (pre- and post-test) is expected for covered indications and should be documented when submitting authorization requests.

• Include counseling documentation with prior authorization submissions

Repeat testing: documentation requirement and denial risk

Requests for repeat testing must include clear documentation of the need (e.g., recurrence of disease or change in disease behavior); without such documentation requests may be denied.

• Testing is generally once in a lifetime; show why repeat testing is medically necessary

Relevant CPT/molecular codes (callout duplicate)

The policy lists specific CPT and panel codes for hereditary colon cancer testing (see codes such as 81201, 81202, 81294–81301, 81317–81319, 81401, 81406, 81435, 81436); prior authorization may be required per payer practice.