Genetic testing prior authorization criteria and request form
Customize your policy alerts
Sign up for all Aspirus Arise policy alerts
Know when Aspirus Arise releases new policies or updates existing guidance.
Monitor payer policy activity
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.
No material clinical or coverage changes in this revision.
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:
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.
Form Coding Fields (to be completed by ordering provider)
| Form contains fields for CPT Code(s), number of units requested, start/end dates — specific CPT codes must be supplied by ordering provider. |
| Form contains fields for ICD-10 diagnosis codes; specific diagnosis codes to be provided by ordering provider. |
What the Ordering Provider Must Do
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.
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.
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.
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.
Defined Terms
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.