CurrentBlue Cross Blue Shield - WisconsinPolicy G-23002

Genetic Testing: Once per Lifetime

This reimbursement policy governs payment for specified germline genetic sequencing tests limited to once per member lifetime for Blue Cross Blue Shield - Wisconsin (and other Anthem BCBS entities) members; applies to providers submitting claims to the payer.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyGenetic Testing: Once per Lifetime

Policy CodePolicy G-23002

Change TypeAdded related coding

Effective DateJul 1, 202617d

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and use correct coding to avoid claim rejection, denial, recoupment, or adjustment.

SourceLink

POLICY UPDATE CHANGES

Updated Related Coding section by adding new codes.

once per lifetimesequencing allowed

not reimbursablereinterpretation reimbursement

WI + multiple statesgeographic applicability

10/23/2025last review

Once-per-Lifetime Sequencing Coverage

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Once-per-lifetime sequencing coverage

Covered when ALL of the following are met:

ALL of the following

The service is one of the genetic sequencing procedures listed in the Related Coding section (Genetic Sequencing: Once per Lifetime Procedures).
The procedure is being billed for germline genetic sequencing (germline genotype is stable across a member's lifetime).
The service has not previously been reimbursed for the member (limited to once per member lifetime).
Reinterpretation of previously obtained sequence results is not billed as a separate reimbursable sequencing procedure (repeat sequencing is not required for reinterpretation or re-analysis).

Related Procedure Codes and Frequency

Genetic sequencing — once per lifetime proceduresmixedCovered

No codes listed

Reimbursement frequency limit — once per member lifetime

LimitOnce per member lifetime for the genetic procedures listed in the Related Coding section; repeat sequencing is not required for future interpretation or re-analysis.

Reinterpretation reimbursementReinterpretation of original sequencing results is not separately reimbursable.

ApplicabilityApplies to the genetic procedures indicated in the Related Coding section of this policy.

Authorization, Claim Submission, and Documentation

Prior Authorization

Authorization, Coding, Documentation, and Claim Submission Requirements

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence. Use proper billing and submission guidelines and industry-standard CPT, HCPCS, and/or revenue codes that are fully supported in the medical record or office notes. Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, recovery/recoupment of payment, or adjustment of reimbursement.

Obtain any required prior authorization and document medical necessity per the member's benefit and state requirements.
Bill services with appropriate CPT, HCPCS, and/or revenue codes; ensure codes are supported by the medical record and office notes.
Noncompliance with coding or policy may lead to claim rejection, denial, recoupment, or payment adjustment.

Key Terms

Germline — definition

TermGermline

DefinitionCells arising from the germ cells containing genetic code that may be passed down to future generations; may also be referred to as hereditary or constitutional.

Clinical noteGermline changes are inheritable and distinct from somatic mutations.

Genotype — definition

TermGenotype

DefinitionThe individual organism's unique set of all the genes.

Clinical noteGenotype represents the inherited genetic makeup of an individual.

Sequencing — definition

TermSequencing

DefinitionDetermining the identity of each nucleotide (one of the four chemical building blocks) that make up a DNA molecule to identify genetic information in a DNA segment.

Clinical noteSequencing provides the base-by-base order of DNA necessary for variant detection.

Variant — definition and classification

TermVariant

DefinitionA nucleotide deviation from a reference DNA sequence; for clinical testing, variants are classified as Pathogenic, Likely pathogenic, Variant of uncertain (or unknown) significance (VUS), Likely benign, or Benign.

Classification noteAs evidence evolves, previous classifications may require modification; laboratories assign risk assessments using accepted classification schemes and may consider patient information when classifying variants.