Genetic Testing: Once per Lifetime
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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.
Updated Related Coding section by adding new codes.
Once-per-Lifetime Sequencing Coverage
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
| No codes listed |
Authorization, Claim Submission, and Documentation
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
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