Hereditary Cancer Genetic Testing (Hereditary Cancer Susceptibility Panels and Gene-Specific Testing)
Policy governing medical necessity and coding for genetic testing to evaluate hereditary cancer susceptibility, including panel and single-gene tests; applies to providers submitting claims to Ambetter Nevada. Pre- and post-test genetic counseling is strongly advised.
Multiple coding and test-name updates were made across the policy reference table, including replacing certain panel names, adding or removing specific CPT/PLA/HCPCS codes, and standardizing 'Targeted Variant' nomenclature to 'Targeted Variant - Single Test (GeneDx)' for many genes.
Replaced multiple targeted-variant test vendor names and CPT/HCPCS codes across many gene-specific entries (e.g., replace 81403 with 81479; replace 81405 with 81404; add 81307, 81321, 81351 in some panel lists).
Multiple criteria sets were clarified, simplified, or reorganized (examples: Hereditary Breast Cancer Panels, PTCH1/SUFU criteria renumbering, PALB2 criteria removed from some panel minimum gene lists).
CDKN2A sequencing and/or deletion/duplication analysis is now COVERED to align with guidelines.
Minor expansions to BRCA1/BRCA2 and PALB2 criteria to allow coverage for additional clinical indications (added ampullary adenocarcinoma).
BRCA1/BRCA2 criteria updated: age threshold for breast cancer coverage changed from <=50 to <=65 and prior-probability threshold changed from >5% to >2.5% per updated NCCN/ASCO guidance; added additional clinical scenarios (e.g., ampullary adenocarcinoma, intermediate-risk prostate cancer with intraductal/cribriform histology).
CDKN2A testing changed to use 'familial atypical multiple mole melanoma (FAMMM)/melanoma-pancreatic cancer syndrome' terminology and removed age >=18 requirement.
Multiple tumor-profile-triggered germline criteria were standardized to the format 'A pathogenic or likely pathogenic variant in [GENE] was identified by tumor profiling in the member and germline analysis has not yet been performed.'
Added recommendation that post-test genetic counseling consider referral to research programs for VUS reclassification.
Added new test to the Policy Reference Table - ProstateNow Prostate Germline Panel (GoPath Diagnostics) - 0475U.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.