CurrentAspirus ArisePolicy N/A

Genetic testing prior authorization criteria and request form

This document is a prior authorization form and criteria checklist for genetic and molecular testing requests submitted to Aspirus Arise. It defines clinical documentation and provider requirements that must be met and submitted to support medical necessity for genetic tests.

Policy Summary

PayerAspirus Arise

PolicyGenetic testing prior authorization criteria and request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must complete and fax the genetic testing prior authorization form with supporting clinical documentation, including genetic counseling documentation when applicable, to Clinical Intake (fax 715.787.7317).

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POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9explicit checklist criteria items

1fax number for submission

715.787.7317clinical intake fax

Genetic Testing Medical Necessity Criteria

General medical necessity criteria for genetic testing

Genetic testing is covered when ALL of the following are met and documented:

Policy Summary

PayerAspirus Arise

PolicyGenetic testing prior authorization criteria and request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

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ALL of the following

Personal or family medical history suggesting a genetic mutation that increases risk for a specific medical condition.
Include relevant family/personal history documentation and pedigree when available.
- Clinical impact may include
  - The disease is treatable and/or preventable.
  - The results will change the frequency, intensity, or type of surveillance or treatment of the condition.
  - The change in medical management is highly likely to result in reduced risk of morbidity and/or mortality.
Testing recommendations are in accordance with existing guidelines (e.g., NCCN, ACMG, ACOG, Medicare, Medicaid).
The test is FDA and CLIA approved.
The test has demonstrated clinical validity in peer-reviewed literature.
The patient has not had prior genetic testing for the same disease/condition (genetic testing generally performed once in a lifetime).
The ordering provider is the provider who will use the results to manage the patient.
- ANY of the following
  - Counseling provided by a board-eligible or board-certified genetic counselor.
  - Counseling provided by a medical geneticist.
  - Counseling provided by another provider with genetics expertise (e.g., oncologist, surgeon, gastroenterologist).
Submission of supporting clinical documentation with the prior authorization request.
Failure to provide required documentation may result in denial.

What the Ordering Provider Must Do

Prior Authorization

Submit prior authorization with supporting documentation

Complete and fax the genetic testing prior authorization form along with supporting clinical documentation to Clinical Intake at fax 715.787.7317. Documentation must support medical necessity and demonstrate how test results will impact patient management.

Fax: Clinical Intake at 715.787.7317
Attach clinical records showing how results will change management and meet medical necessity criteria.

Documentation Required

Include genetic counseling documentation when clinically appropriate

When clinically appropriate, attach documentation of genetic counseling that includes a pedigree, risk assessment, informed consent, and discussion of test limitations and psychosocial implications performed by an approved genetics professional affiliated with the testing laboratory.

Acceptable providers: board-eligible/board-certified genetic counselor, medical geneticist, or other provider with genetics expertise affiliated with the testing lab.

Documentation Required

Ordering provider requirement

The ordering provider must be the clinician who will use the test results to manage the patient; ensure the ordering provider information on the form reflects this.

Ordering provider name and NPI must be provided on the form; the ordering clinician attests that results will be used to directly impact management.

Denial Risk

Risk of denial if criteria or documentation missing

Failure to provide required documentation or evidence that the medical necessity criteria are met may result in denial of the request.

Ensure all requested clinical documentation and checklist attestations are included when submitting the prior authorization form.

Clinical and Operational Context

This form operationalizes Aspirus Arise's medical necessity criteria for genetic testing requests: testing is expected only when results will change management, follow accepted guidelines, be performed by approved tests/labs, and typically not repeated if previously performed for the same condition. The form requires submission of supporting clinical documentation and attestation that results will be used to directly impact patient management. Failure to provide required documentation may result in denial of the request.

This document serves as a prior authorization form and criteria checklist for genetic and molecular testing requests submitted to Aspirus Arise. It defines the clinical documentation and provider requirements that must be met and submitted to support medical necessity for genetic tests, including evidence that testing recommendations align with established guidelines and that testing is clinically valid and appropriately indicated.

Form & Submission Details

The form captures patient identifying information (name, Aspirus ID, date of birth, contact) and requires providers to populate these fields.

The form captures ordering provider details (name, clinic, NPI, address, phone, fax) and indicates network status; providers must complete these fields.

The form captures servicing provider details (name, NPI, address, phone, fax, email) and requires completion by the servicing provider where applicable.

A contact person for questions (name, phone, fax, email) is requested on the form to facilitate inquiries about the request.

The form includes fields for CPT code(s), number of units requested, and start/end dates; the ordering provider must supply the specific CPT codes and units.

The form includes fields for ICD-10 diagnosis codes and a description of the request; the ordering provider must provide applicable diagnosis codes and supporting clinical rationale.

This document is a prior authorization request tool and does not itself list explicit CPT/ICD codes or state-specific applicability within the policy text; providers must supply the specific codes and complete the form for submission.

Operational quick facts

explicit checklist criteria items9

fax number for submission1

clinical intake fax715.787.7317

OpenPayer

Genetic testing prior authorization criteria and request form

Genetic Testing Medical Necessity Criteria

Form Coding Fields (to be completed by ordering provider)

What the Ordering Provider Must Do

Clinical and Operational Context

Form & Submission Details

Defined Terms