Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA)
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Defines coverage, medical necessity criteria, and prior authorization requirements for proprietary genetic and multianalyte laboratory tests (PLA/MAAA) for BCBSRI members, applying to Medicare Advantage and Commercial Products.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Medical necessity criteria
Covered when ALL of the following general conditions are met (examples provided):
InterQual criteria is used in the online authorization tool for many determinations.
First- and second-degree relatives are defined in policy (first-degree: biological parent, brother, sister, child; second-degree: grandparent, aunt, uncle, niece, nephew, grandchildren, half-sibling).
Services are not covered for Medicare Advantage Plans and are not medically necessary for Commercial Products when there is insufficient clinical evidence, results would not reasonably be used in patient management, or services are unlikely to impact therapeutic decision-making. Laboratories are not permitted to obtain authorizations or participate in the authorization process on behalf of the ordering physician; only the ordering physician may be involved in authorization, appeal, or other administrative processes.
Some Commercial Product members may also be subject to contract exclusions for expanded biomarker testing per plan-specific benefit booklets and the Biomarker Testing Mandate policy; refer to the Coding section and the member's benefit booklet for plan-specific coverage determinations.
An entire genetic panel test is considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products when there is insufficient evidence that the panel or the specific gene/variant would influence treatment decisions and improve net health outcomes. When evidence is lacking that any component of a panel will change management, the entire panel may be denied; for specific panel components filed with individual CPT codes, refer to the attached code grid and the Genetic Testing Services policy for coverage guidance.
Covered Indications
Covered indications — Examples of appropriate uses
Coding and Billing
| see attached grid | Detailed PLA/MAAA CPT codes and coverage status are listed in the attached code grid referenced by the policy. |
Provider Actions and Authorization Requirements
Prior authorization required for grid-listed tests
Prior authorization is required for tests listed in the attached PLA/MAAA code grid for Medicare Advantage Plans and is recommended for Commercial Products; for panel testing, each CPT code component must be entered and processed separately through the online authorization tool.
- Prior authorization required for Medicare Advantage Plans; recommended for Commercial Products.
- Panel testing: each component/gene represented by multiple CPT codes requires a separate prior authorization entry and processing.
PCP exemption for Fully‑Funded Commercial Products (effective 10/1/2025)
Effective 10/1/2025, Fully-Funded Commercial Products may exempt prior authorization when the requesting physician is an in‑network BCBSRI contracted primary care provider in one of the listed specialties (Internal Medicine; Pediatric Medicine; Family Practice; Obstetrics and Gynecology; DO; NP/PCP; PA). This exemption does not apply to Self‑Funded Commercial Products or Medicare Advantage Plans.
- Applies only to Fully‑Funded Commercial Products and only when the requesting physician is a BCBSRI contracted PCP in the specified specialties.
- Prior authorization still required for Self‑Funded Commercial Products and Medicare Advantage Plans.
Ordering physician must control authorization and administrative processes
Only the ordering physician must initiate and be involved in the authorization, appeal, or administrative processes for genetic testing; laboratories and third parties are not permitted to obtain clinical authorization or act on behalf of the ordering clinician.
- The ordering physician shall be the sole party involved in authorization, appeals, or related administrative tasks.
- Laboratories may not obtain authorization or participate in the authorization process on behalf of the ordering physician.
How to submit prior authorization
Submit prior authorization requests using the BCBSRI online prior authorization tool (available to BCBSRI‑participating providers). Providers who do not have access to the online tool must fax requests to Utilization Management at (401) 272‑8885. If a genetic test is not found in the online tool, fax the request to Utilization Management at (401) 272‑8885.
- Use BCBSRI online prior authorization tool for participating providers.
- Fax non‑participating provider requests or requests for tests not listed in the online tool to Utilization Management at (401) 272‑8885.
Prohibition on laboratory/third‑party obtaining or supporting authorization
If a laboratory or any third party obtains authorization on behalf of the ordering physician, assists in the authorization process, or prepares documentation supporting authorization/appeal, BCBSRI will deem this a policy violation and may take severe action up to termination from the BCBSRI provider network; services provided without authorization may be denied as the financial liability of the participating laboratory and may not be billed to the member.
- Laboratory/third‑party obtaining or supporting authorization is a policy violation subject to severe action, up to termination.
- Unauthorized laboratory services may be denied and billed to the laboratory rather than the member.
Missing required prior authorization will lead to denial
Services for which prior authorization is indicated in the attached code grid will be denied if the required authorization is not obtained; when a panel is represented by multiple CPT codes, each component without its own authorization entry may be denied.
- Missing prior authorization for grid‑listed services will result in denial.
- Panel components represented by multiple CPT codes each require individual authorization; missing entries may be denied per component.
Ordering physician responsibility for authorization and appeals
Ensure the ordering physician initiates authorization requests and remains the point of contact for authorization, appeals, and administrative communications; do not rely on laboratories or third parties to manage authorizations.
- Ordering physician must be the party to request and manage authorization and any appeals.
- Laboratories and third parties must not be used to obtain or facilitate authorizations.
Laboratories may not obtain authorization on behalf of ordering clinicians
Only the ordering physician shall be involved in authorization, appeal, or administrative processes; laboratories are explicitly not allowed to obtain clinical authorization or participate in the authorization process on behalf of the ordering physician.
- Laboratories cannot obtain authorization, facilitate the authorization process, or prepare documentation of clinical appropriateness on behalf of the ordering clinician.
- Violations are subject to severe action by BCBSRI, including termination from the provider network.
Member Eligibility Requirements
Coverage of proprietary genetic and multianalyte laboratory tests requires that the requested testing meet the medical necessity criteria used in the online authorization tool (InterQual) and any additional panel-specific criteria described in this policy. For carrier screening (preconception or prenatal), the policy requires that one or both individuals have a first- or second-degree relative affected, or one individual is a known carrier, or the individuals belong to a population with an elevated carrier rate, and that previous carrier screening or targeted testing for the variant(s) of interest has not been performed.
General eligibility for genetic testing is limited to situations where testing of an individual's germline will provide clinical benefit, such as to confirm a suspected diagnosis in a symptomatic patient, to identify a causative etiology for a clinical syndrome with multiple possible causes, or to assess future disease or cancer risk in an asymptomatic individual. Panel tests remain subject to additional policy criteria and prior authorization requirements.
Not Covered Services
Panels and multigene tests are not covered when there is insufficient evidence that the results would impact clinical management or improve net health outcomes. In such cases the entire panel may be denied for Medicare Advantage and deemed not medically necessary for Commercial Products. Additionally, certain genetic testing services may be explicit contract exclusions for some self-funded Commercial groups; check the member's benefit booklet and the Coding section of this policy for plan-level exclusions.
Background
Proprietary Laboratory Analyses (PLA) are alphanumeric CPT descriptors used for proprietary clinical laboratory tests; they may be issued for a single-source laboratory or licensed to multiple laboratories. PLA and Multianalyte Assays with Algorithmic Analyses (MAAAs) may or may not be FDA-cleared and are often unique to a particular laboratory or manufacturer. These assays combine multiple analyte results and apply algorithmic analysis to produce a score or probability; they are subject to the same medical necessity, coding, and prior authorization requirements outlined in this policy.
Panel testing increases breadth of testing but may also increase the yield of variants of uncertain significance and potential harm if results would not change clinical management; therefore panel tests are subject to additional criteria and review in the online authorization tool.
Key Definitions
Revision History
Policy effective date set to 06/01/2026.
Policy last reviewed on 04/01/2026.
Provider Update published January/February 2026 referencing this policy.
PCP exemption for prior authorization in Fully-Funded Commercial Products effective 10/01/2025.
Provider Update issues published in 2025 (Jan/Feb/May/July/Sep/Nov) referencing ongoing policy communications.
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