CurrentCareSourcePolicy N/A

Genetic Testing and Counseling - AR PASSE

Policy governing medical necessity, prior authorization, and genetic counseling requirements for germline and somatic genetic testing for members in the Arkansas PASSE program.

Policy Summary

PayerCareSource

PolicyGenetic Testing and Counseling - AR PASSE

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2023

Next Review DateN/A

Key ActionObtain prior authorization when required and document genetic counseling (including a three-generation family history when available) for germline testing to establish medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1genetic counseling required (germline)

bothtest types addressed

MCGmedical necessity reference

not specifiedlab accreditation stated

excludedHLA coverage

Coverage Criteria

General coverage criteria

Covered when ALL of the following are met (as applicable):

Medical necessity review: Genetic testing (somatic or germline) requires review for medical necessity using published MCG criteria and the Medical Necessity Determinations administrative policy.

Prior authorization may be required for genetic testing, including both somatic and germline tests; proprietary panels require evidence-based documentation and may be denied if they do not meet medical necessity, in which case individual genetic tests may be requested instead.

Germline genetic counseling: Germline genetic testing is covered only when genetic counseling is provided by a healthcare professional with education and training in relevant genetic issues, is free of commercial bias with disclosure of conflicts, and includes all of the following: calculation and communication of genetic risks after obtaining a three-generation family history when available; discussion of natural history and heredity; discussion of possible impacts of testing; discussion of possible outcomes (positive, negative, variant of uncertain significance); explanation of potential benefits, risks, and limitations; explanation of purpose of evaluation; identification of medical management issues (prevention, surveillance, treatment options) and their implications; and obtaining informed consent.

Policy Summary

PayerCareSource

PolicyGenetic Testing and Counseling - AR PASSE

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2023

Next Review DateN/A

Key ActionObtain prior authorization when required and document genetic counseling (including a three-generation family history when available) for germline testing to establish medical necessity.

SourceLink

On This Page

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Provider Actions and Requirements

Prior Authorization

Prior authorization and proprietary panel requirements

Prior authorization may be required for genetic testing (both somatic and germline). Proprietary panel testing requires evidence-based documentation per the Medical Necessity Determinations administrative policy and may be denied if the panel does not meet medical necessity.

Prior authorization applies to somatic and germline genetic testing.
Proprietary panels require evidence-based documentation per Medical Necessity Determinations.

Step Therapy

Panel-to-single-test step

If a proprietary panel does not meet medical necessity, CareSource may request that individual genetic tests be ordered separately instead of covering the full panel.

Individual genetic tests may be requested based on the Medical Necessity Determinations administrative policy when panels fail to meet criteria.

Documentation Required

Required documentation for medical necessity and counseling

Documentation must demonstrate medical necessity using published MCG criteria and the Medical Necessity Determinations administrative policy; for germline testing include evidence of genetic counseling with a three-generation family history when available and informed consent.

Support medical necessity per published MCG criteria and Medical Necessity Determinations.
For germline testing, document genetic counseling components including a 3-generation family history when available and informed consent.

Denial Risk

Prior authorization and medical necessity — denial risk

Lack of required prior authorization or failure to meet medical necessity based on published MCG criteria and the Medical Necessity Determinations policy may result in denial of coverage.

CareSource will review for medical necessity using published MCG criteria and the Medical Necessity Determinations administrative policy.

Documentation Required

Genetic counseling required for germline testing

Genetic counseling is required for all germline genetic testing and must be provided by a healthcare professional with education and training in genetic issues relevant to the tests under consideration.

Counseling must include the specified counseling process (see policy) and be free of commercial bias.

Note

Acceptable counseling providers

Genetic counseling may be provided by a certified genetic counselor or another qualified healthcare professional when access issues require it, provided the counselor has education and training in relevant genetic issues and discloses conflicts of interest.

Counseling providers must be free of commercial bias and disclose potential or real conflicts of interest.
When a certified genetic counselor is not available, other qualified healthcare professionals may provide counseling.

Definitions

Genetic Screening

DefinitionGenetic Screening — the process of testing a population for a genetic disease to identify people who have the disease or who may pass it on to offspring.

PurposeIdentify disease cases or carrier status within a population.

ScopeApplies to population-level testing rather than testing of a single symptomatic individual.

Use-case exampleNewborn screening programs or carrier screening in specific populations.

Genetic Testing

DefinitionGenetic Testing — a medical test that identifies changes in genes, chromosomes, or proteins to confirm or rule out a suspected genetic condition, either hereditary or acquired.

IncludesTests for germline (inherited) and somatic (acquired) changes.

PurposeConfirm or exclude suspected genetic conditions and guide diagnosis or treatment decisions.

Relation to precision medicineProvides genetic information that can inform targeted therapies.

HLA Typing

DefinitionHuman Leukocyte Antigen (HLA) Typing — a test used to match patients and donors for bone marrow or cord blood transplants.

Primary useDonor/recipient matching for hematopoietic stem cell transplantation.

Policy noteHLA typing is excluded from this genetic testing policy and does not require pre-authorization under this policy (see coverage exclusions).

Sample contextPerformed when evaluating transplant compatibility rather than for inherited disease diagnosis.

Inherited Genetic Variant

DefinitionInherited Genetic Variant — a type of DNA sequence change passed from parent to offspring (germline).

Also calledGermline variant.

ImplicationMay have implications for family members and typically requires genetic counseling when tested.

Testing contextGermline testing covered when counseling and medical necessity criteria are met.

Somatic Gene Variant

DefinitionSomatic Gene Variant — a type of DNA sequence change that is not inherited from a parent but acquired during a person's life.

Also described asAn acquired (non-germline) mutation.

Clinical relevanceOften relevant to cancer and may guide targeted therapies; somatic testing does not require the germline counseling process described for inherited testing.

Coverage contextSomatic genetic testing is addressed separately from germline testing in coverage criteria.

Precision Medicine

DefinitionPrecision Medicine — a field of medicine that selects pharmacotherapies based on the patient's genetics.

GoalTailor treatments to individual genetic profiles to improve efficacy and reduce adverse effects.

Relation to testingRelies on genetic testing results (somatic or germline) to inform therapy selection.

Clinical applicationSelecting targeted cancer therapies or selecting medications based on pharmacogenomic results.

OpenPayer

Genetic Testing and Counseling - AR PASSE

Coverage Criteria

Provider Actions and Requirements

Eligibility Requirements

Definitions

Background

Not Covered