Baylor Scott & White Health Plan Genetic Testing Coverage

Coverage Criteria

General medical necessity criteria — Covered when ALL of the following are met.

Covered when ALL of the following are met:

ALL of the following

Appropriate genetic counseling occurs before and after testing. Counseling must be by a practitioner with expertise in the genetic aspects of the condition being evaluated and who will discuss the results and clinical implications.
Documentation of counseling must accompany the preauthorization request. Evidence should include discussion of possible results (positive, negative, uncertain), test limitations, risk evaluation, inheritance patterns, informed consent, and a plan for post-test counseling. Counseling must not be performed by practitioners employed by testing companies due to conflict of interest.
There is a reasonable expectation, based on family history, three-generation pedigree (where appropriate), risk factors, and/or symptomatology, that a genetically inherited or acquired condition exists or the member is at direct risk of inheriting the mutation (pre-symptomatic).
A three-generation pedigree MUST accompany the request where appropriate.
Knowledge of the presence or absence of the condition would directly affect medical care of the member.
The disease must be treatable and/or preventable, and the test results must lead to a change in surveillance frequency and/or treatment intensity for that disease.
The requested test is the smallest, most targeted study expected to answer the clinical question (single-gene test preferred when appropriate; panels allowed only when multiple genes plausibly explain the disorder).
Multigene panels must list included genes and rationale; broad panels are not medically necessary when a focused test is available. Multiple panels tested concurrently are not medically necessary.
The test is performed in a CLIA-certified laboratory, is FDA-approved when applicable, and is recommended by recognized national guidelines.
When possible, testing should be performed at a contracted/network laboratory. If a non-contracted lab is used, the provider must document the need and inform the member of potential out-of-pocket differences.
The request is submitted with the Baylor Scott & White Health Plan 'Statement of Medical Necessity for Genetic Testing' or equivalent documentation that answers the required justification questions and clearly explains how results will improve or change medical management.
A generic statement that a test 'is medically necessary' is insufficient; the request must state specific changes in management or surveillance that would occur with positive or negative results.
Testing frequency limits are respected (generally once per lifetime for a specific mutation or panel, or once per pregnancy for prenatal testing), unless justified by changed guidelines or need for reinterpretation of results.
Exceptions may be considered with supporting rationale.

Specific test guidance — Tests with specific policy guidance.

Tests with specific policy guidance:

ALL of the following

Cell-free DNA screening tests for microdeletions (CPT 81422) are NOT medically necessary.
Whole genome sequencing may be medically necessary in clinically affected neonatal and pediatric patients to identify or confirm a genetic etiology when targeted studies have failed.
In most cases whole genome sequencing will not be found medically necessary unless more targeted studies have failed to identify a mutation.

Coverage contingent on completed prior authorization and clinical justification.

Coverage is contingent on completion of prior authorization and provision of clinical justification. Requests must include answers to the clinical justification questions below and supporting documentation.

ALL of the following

A completed prior authorization is required before testing is performed.
Preauthorization must include documentation described in this policy (counseling documentation, pedigree when appropriate, laboratory information, and Statement of Medical Necessity or equivalent).
Provider must justify the clinical indication for each requested test by addressing the specific questions in the Statement of Medical Necessity or the provided Medical Information form.
Required questions include: why the test is appropriate; whether the beneficiary exhibits clinical features or a family member has an identified variant; evidence of informed consent and genetic counseling; scientific validity of the test; willingness to undergo potential interventions; how results will specifically alter medical management; test cost; and whether a multigene panel is more cost-effective than individual tests.
Requests lacking required justification, pedigree, evidence of counseling/informed consent, or a clear explanation of how results will change management are subject to denial.

Predictive/diagnostic/prognostic testing when reasonable expectation based on family history/pedigree/risk/symptoms that a genetic condition exists and results will directly affect medical management.

Predictive/diagnostic/prognostic testing — Covered when:

ALL of the following

There is reasonable expectation based on family history, pedigree, risk factors, and/or symptoms that a genetic condition exists and testing results will directly affect medical management.
A three-generation pedigree must accompany requests where appropriate.

Whole genome sequencing in clinically affected neonatal and pediatric patients when targeted studies have failed.

Whole genome sequencing —

ALL of the following

May be medically necessary in clinically affected neonatal and pediatric patients when more targeted studies have failed to identify a mutation.
Whole genome sequencing is generally not medically necessary unless targeted testing has been unsuccessful.

Requirement that provider justify clinical indication for each requested test per listed questions; must document how results will alter management and provide references.

Provider must justify clinical indication for each requested test by answering the following and providing supporting references where applicable:

ALL of the following

Why is the test appropriate for the patient?
Does the beneficiary exhibit clinical features of the mutation in question? If not, has a genetic variant been identified in a family member?
Has the patient given informed consent to the genetic test?
Has genetic counseling been provided?
What is the scientific validity of the testing? Provide references or links.

There are no additional explicit exclusions in this section beyond those listed; requests missing required clinical justification or documentation may be denied as outlined above.

Coding and Frequency Limits

Genetic Test CPT/Procedure Codes with PA specificationsCPT

81161	DMD (dystrophin) deletion/duplication analysis
81220	CFTR gene analysis; common variants
81221	CFTR gene analysis; known familial variants
81222	CFTR gene analysis; duplication/deletion variants
81223	CFTR gene analysis; full gene sequence
81224	CFTR intron 8 poly-T analysis
81229	Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities
81238	F9 gene analysis (hemophilia B)
81243	FMR1 gene analysis (fragile X)
81259	HBA1/HBA2 gene analysis (alpha thalassemia)

1–10 of 19

1/2

Notes on code applicabilitymixed

No codes listed

Form placeholders for ICD-10 and CPT codesmixed

ICD-10 Codes:	Placeholders on form for diagnosis codes supporting the test request
CPT Code, 1 = Test. CPT Code, 2 = CPT Code. CPT Code, 3 = Test.	Placeholders on form for CPT codes associated with requested genetic tests

Testing frequency limit

Frequency limitMost genetic/genomic testing is limited to once per lifetime (or once per pregnancy for prenatal testing); exceptions possible based on clinical need.

ScopeApplies to most hereditary single-gene tests, multigene panels, and genomic tests unless otherwise specified.

Prenatal notePrenatal testing may be limited to once per pregnancy.

Documentation for exceptionsRequests for testing more than once require documented medical necessity and justification in the prior authorization request.

Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Genetic/genomic testing (including specific CPT/HCPCS codes) requires prior authorization. Requests must include the diagnosis and clinical documentation supporting medical necessity. Use the SWHP Genetic Testing Prior Authorization Form for submission.

PA required for listed genetic test CPT/HCPCS codes (see policy code list)
Include diagnosis and documentation with PA request
Use SWHP Genetic Testing Prior Authorization Form

Prior Authorization

Submit SWHP Prior Authorization Form

Submit the SWHP Genetic Testing Prior Authorization Form (most recent version) with each request. The form captures member and provider identification, supplying provider details, requested test(s), ICD-10 and CPT codes, and a dedicated Medical Information section that must be completed to justify each test.

Form fields required: member name, SWHP ID, DOB, gender

Eligibility Requirements

Where appropriate, requests for genetic testing must be accompanied by a three-generation pedigree to support family history and risk assessment. Coverage decisions will be based on the documentation provided (pedigree, clinical notes, responses on the prior authorization form) demonstrating that testing meets the medical necessity criteria.

No additional top-level eligibility exceptions are specified in this policy segment. Eligibility for coverage is determined by the medical necessity criteria and the documentation supplied with the prior authorization request.

The prior authorization form explicitly asks whether a familial variant has been identified and requests justification of clinical features when the patient does not exhibit phenotype. Providers must answer these form questions and supply clinical rationale; the policy does not establish any universal eligibility exceptions in this segment—each request is evaluated based on the completed form and supporting documentation.

Definitions

First‑degree relative definition

DefinitionFirst-degree relative: a blood relative with whom an individual shares approximately 50% of his or her genes, including parents, full siblings, and children.

ExamplesParents, full siblings, children.

RelevanceUsed to determine family risk when assessing clinical indication for genetic testing.

Second‑degree relative definition

DefinitionSecond-degree relative: a blood relative with whom an individual shares approximately 25% of his or her genes, including grandparents, grandchildren, aunts, uncles, nephews, nieces, and half-siblings.

ExamplesGrandparents, aunts/uncles, nieces/nephews, half‑siblings.

Not Covered / Not Medically Necessary

Not covered: Genetic testing performed solely for non-medical purposes (including paternity, ancestry testing, GWAS, and non-disease trait testing), and routine or ongoing long-term genetic counseling services are examples of services that will not be authorized under this policy.

Not covered: Cell-free DNA microdeletion screening (CPT 81422) is specifically stated as not medically necessary and is therefore not covered.

This document segment does not list additional specific tests or indications as not covered beyond the items already called out. However, the policy emphasizes that lack of clinical justification or missing required documentation on the prior authorization form can result in denial or non-coverage.

Background

Genetic testing is intended for predictive, diagnostic, or prognostic purposes. Testing should be performed only when there is a reasonable expectation—based on family history, pedigree analysis, risk factors, or symptomatology—that an inherited or acquired genetic condition exists and when results are expected to directly affect medical management (treatment or surveillance). Prior to testing, providers must ensure appropriate pre-test genetic counseling by a practitioner with expertise and document how results would change patient care.

OpenPayer

Genetic (Genomic) Testing Coverage Criteria

Coverage Criteria

Coding and Frequency Limits

Provider Actions & Prior Authorization

Eligibility Requirements

Definitions

Not Covered / Not Medically Necessary

Background