CurrentBlue Cross Blue Shield - WisconsinPolicy G-23002

Genetic Tests: Once per Lifetime — Reimbursement Policy

Defines Anthem Medicare Advantage / BCBSWI reimbursement stance that specific germline genetic sequencing procedures are reimbursed only once per member's lifetime and affects providers submitting claims for these tests under the payer's laboratory reimbursement policies.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyGenetic Tests: Once per Lifetime — Reimbursement Policy

Policy CodePolicy G-23002

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review Date

Key ActionDo not bill for repeat sequencing for the same member — reimbursement is limited to one sequencing event per lifetime and reinterpretation is not separately reimbursable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

once per lifetimereimbursement limit

not reimbursablereinterpretation

01/01/2024effective

06/14/2023last review

Coverage Criteria

Once-per-lifetime genetic sequencing coverage

Covered when ALL of the following are met:

Reimbursement is limited to one lifetime sequencing event for the specified germline genetic tests; the listed genetic sequencing procedures are limited to once per member lifetime.

Reinterpretation or reanalysis of previously sequenced data (reinterpretation of the original results) is not separately reimbursable; repeat sequencing is not required for future interpretation.

Services meet applicable authorization and medical necessity requirements and are billed with appropriate industry-standard CPT/HCPCS/revenue codes supported by the medical record.

Coding

Related genetic sequencing procedure codes (referenced)mixed

No codes listed

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyGenetic Tests: Once per Lifetime — Reimbursement Policy

Policy CodePolicy G-23002

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review Date

Key ActionDo not bill for repeat sequencing for the same member — reimbursement is limited to one sequencing event per lifetime and reinterpretation is not separately reimbursable.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions and Billing

Prior Authorization

Authorization and billing requirements

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis. Follow proper billing and submission practices and use industry-standard, compliant codes (CPT, HCPCS, revenue codes). Claims must be fully supported in the medical record and/or office notes. Failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, recovery/recoupment of payment, or adjustment of reimbursement to reflect appropriate services performed.

Use CPT, HCPCS, and/or revenue codes that accurately describe services performed
Ensure documentation in the medical record/office notes supports billed codes
Prior authorization and medical necessity requirements apply where indicated
Anthem may reject/deny claims, recover payments, or adjust reimbursement if guidelines are not followed

Billing Rule

Once-per-lifetime limitation

Genetic sequencing procedures listed in Related Coding are limited to once per member lifetime. Because a member's germline genotype does not change during their lifetime, repeat sequencing is not routinely reimbursable. Reinterpretation or reanalysis of previously generated sequence data is not separately reimbursable as a new sequencing procedure.

Once-per-lifetime limitation applies to genetic sequencing procedures listed in Related Coding
Reinterpretation of original sequencing results is not separately reimbursable
Exceptions only apply if provider, state, or federal contracts and/or requirements indicate otherwise

Definitions

Genotype

DefinitionGenotype: the individual organism's unique set of all the genes; may be referred to as hereditary or constitutional

ScopeRefers to germline genes in cells arising from germ cells that may be passed to future generations

Relevance to policyGermline genotype does not change during a member's lifetime, supporting once-per-lifetime sequencing coverage

Sequencing

DefinitionSequencing: determining the identity of each nucleotide (one of the four bases) in a DNA segment to identify the genetic information it carries

PurposeUsed to characterize the precise DNA sequence of a gene or region for clinical testing

ImplicationRepeat sequencing is unnecessary for future interpretation of germline genotype because the underlying sequence does not change

Variant

DefinitionVariant: a nucleotide deviation from a reference DNA sequence

Classification categoriesPathogenic; Likely pathogenic; Variant of uncertain (or unknown) significance (VUS); Likely benign; Benign

Evolving evidenceAs evidence on variants evolves, previous classifications may require modification; each laboratory assigns risk assessment per accepted schemes