What Providers Must Do (Prior Authorization and Submission Notes)

Genetic and molecular tests (examples) require prior authorization. Providers must obtain prior authorization before ordering or submitting claims for the genetic/genomic and molecular pathology codes and panels listed in this policy. Prior authorization helps ensure the test is appropriate for the clinical indication and that documentation supports medical necessity.

• Examples include but are not limited to: BRCA1/BRCA2 full sequence and duplication/deletion analysis (CPT 81161, 81165, 81166), Lynch syndrome panel testing (eg, CPT 0238U and related panels), hereditary cancer genomic panels (eg, CPT 0102U, 0103U, 0214U, 0215U), whole exome/whole genome sequencing and mitochondrial testing (eg, CPT 0214U, 0335U, 0364U, 0297U-0300U, 0314U), targeted tumor and plasma cfDNA panels and large NGS panels (eg, CPT 81455, 81456, 81458, 81459, 81465, 81470, 81471), pharmacogenomic and drug metabolism panels (eg, CPT 81225, 81230, 81350, 81355), tumor-specific expression and recurrence assays (eg, CPT 81518, 81519, 81504), and unlisted or high-complexity molecular procedures (eg, CPT 81401, 81479, 0551U/0531U series).
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• Prior Authorization Required — Genetic/molecular tests (examples)
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• Providers must include the clinical indication, prior test results (if applicable), and documentation that supports medical necessity when submitting a prior authorization request for genetic, genomic, and molecular pathology testing. Tests performed for screening without a documented family history or without meeting specific clinical criteria may be denied as not medically necessary.
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