CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Genetic Testing Services

Defines coverage, medical necessity criteria, prior authorization requirements, and coding guidance for genetic testing services (germline and somatic), including panels, GSPs, and MAAA, for BCBSRI Medicare Advantage and Commercial products effective 2025-10-01.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Genetic Testing Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review Date

Key ActionSubmit authorization requests via the BCBSRI online authorization tool (participating providers) or fax to Utilization Management at (401) 272-8885; enter and process each CPT code separately for panel components.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

appliesApplies to Medicare Advantage and Commercial Products

panel rulePanel component authorization required when represented by multiple CPT codes

PCP exemptFully-Funded Commercial PCP exemption effective 2025-10-01

Coverage Summary

Overview: This coverage criteria document implements a mixed coverage stance for genetic testing services — some tests are covered when medical necessity criteria are met, some are not covered/not medically necessary, and some require prior authorization. It applies to Medicare Advantage and Commercial Products and is effective 2025-10-01. The policy addresses testing for germline and somatic variants, including panel tests, Genomic Sequencing Procedures (GSPs), and Multianalyte Assays with Algorithmic Analyses (MAAAs), and includes both tests requiring authorization and tests considered not covered or not medically necessary.

Medical Necessity Criteria

General Clinical Criteria (applied via online authorization tool / InterQual)

Genetic tests may be considered medically necessary when the criteria in the online authorization tool (InterQual) and/or this policy are met:

ALL of the following

One of the following familial/carrier/population criteria
- Authorization criteria in the online authorization tool (InterQual) are met for the specific test requested
- One or both individuals have a first- or second-degree relative who is affected
  See definitions for second-degree relatives
- One individual is a known carrier
- Previous carrier screening or individual targeted gene testing for the gene variant(s) of interest has not been performed
- One or both individuals are members of a population known to have carrier rate that exceeds threshold considered appropriate for a particular condition

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Diagnostic Germline Testing

Diagnostic germline testing of an individual is considered medically necessary when testing will benefit the individual and one of the following is met:

ANY of the following

To identify a causative etiology for a clinical syndrome for which there are multiple possible underlying conditions
To confirm suspected diagnosis in a patient with signs and/or symptoms of the condition
Testing an asymptomatic individual to determine future risk of disease

Genetic Testing for Cancer

Genetic testing for cancer is medically necessary when at least one of the following is met:

ANY of the following

Testing of cancer cells from an affected individual to benefit the individual by directing targeted treatment based on specific somatic variants
Testing an asymptomatic patient to determine future risk of cancer

Panel Testing Authorization Logic

Panel tests are subject to additional criteria and authorization requirements:

ALL of the following

Panel tests are subject to additional criteria; refer to panel-specific criteria before utilizing general medical necessity criteria
Authorization is required for each component and/or gene/gene variant of a panel when the panel is represented by multiple CPT codes
Each individual CPT code must be entered into and processed through the online authorization tool independently

Not Medically Necessary / Not Covered

Genetic testing services are considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products when any of the following apply:

ANY of the following

There is insufficient clinical evidence or strength of recommendation
Services are unlikely to impact therapeutic decision-making in the clinical management of the patient
Results would not reasonably be used in management of a patient
A gene and/or gene variant alone lacks evidence to guide patient management and improve net health outcomes (entire genetic panel test considered not covered)

Note: The not-covered / not medically necessary rules in this policy apply to Medicare Advantage Plans and Commercial Products, per the policy scope and prior authorization guidance.

Provider Actions & Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required via the BCBSRI online authorization tool for BCBSRI-participating providers. Non-participating providers may fax authorization requests to Utilization Management at (401) 272-8885. If a genetic test is not found in the online authorization tool, fax the request to Utilization Management at (401) 272-8885.

Prior Authorization

Panel Component-Level Authorization

Panel component-level authorization is required — each CPT code representing a component, gene, or gene variant of a panel must be entered into and processed independently through the online authorization tool.

Prior Authorization

Commercial PCP Exemption (Effective 2025-10-01)

Effective 2025-10-01, for Fully-Funded Commercial Products only, prior authorization requests may not be required when the requesting physician is a BCBSRI-contracted Primary Care Provider (PCP). This exemption applies only to Fully-Funded Commercial Products and does not apply to Self-Funded Commercial Products or Medicare Advantage Plans.

Effective date: 2025-10-01
PCP specialties included in the exemption: Internal Medicine; Pediatric Medicine; Family Practice; Obstetrics and Gynecology; Doctor of Osteopathic Medicine; Nurse Practitioner (NP)/Primary Care Provider (PCP); Physician Assistant (PA)

Documentation Required

Authorization Must Be Obtained by Ordering Physician

The ordering physician is responsible for initiating and obtaining prior authorization. Laboratories, vendors, or third parties are not permitted to obtain authorization on behalf of the ordering physician. If a participating laboratory provides a laboratory service that has not been authorized in accordance with this policy, the service will be denied and the financial liability will rest with the participating laboratory.

Billing Rule

Diagnosis Code and Coding Requirements

Coverage and authorization decisions for some genetic tests depend on the diagnosis code submitted with the claim. Refer to the attached code grid and the Comments column for diagnosis requirements and any related policy references when determining whether authorization and coverage criteria are met.

Background

Background (concise): Molecular pathology involves DNA/RNA analyses to detect germline or somatic variants. Genomic Sequencing Procedures (GSPs) and MAAAs simultaneously assay multiple genes or analytes and commonly use next-generation sequencing (NGS). Panel and NGS testing offer efficiency and broader gene coverage but may generate large amounts of ancillary information and more variants of uncertain significance. Analytic and clinical validity and clinical utility of panels, GSPs, and MAAAs are condition-specific and may vary by test and laboratory.

Glossary: Germline variants — variants present in the DNA of every cell from conception. Somatic variants — variants acquired during life restricted to certain cell populations (not usually inherited). Panel test — a test that simultaneously evaluates multiple genes (eg, via NGS) rather than sequential single-gene testing. MAAA — Multianalyte Assays with Algorithmic Analyses; assays combining multiple analytic results with algorithmic analysis, typically unique to a single laboratory.

Evidence summary: Primary external references informing this policy include CMS LCD L35000 (Molecular Pathology Procedures), AMA CPT 2024, and society guidelines and literature such as NCCN, ASCO, ACMG, and ACOG. The attached LCD (L35000) is included under Medicare determinations.

Name	Number/Type
Molecular Pathology Procedures	L35000 / LCD

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Genetic Testing Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review Date

SourceLink

On This Page

OpenPayer

Medical Coverage Policy Genetic Testing Services

Coverage Summary

Medical Necessity Criteria

Not Medically Necessary / Not Covered

Coding

Provider Actions & Authorization Requirements

Background

Medicare Determinations

Revision History