CurrentCareSourcePolicy N/A

Genetic Testing and Counseling — Arkansas PASSE

Defines coverage, medical necessity review, and genetic counseling requirements for germline and somatic genetic testing for CareSource members in the Arkansas PASSE program.

Policy Summary

PayerCareSource

PolicyGenetic Testing and Counseling — Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization when required and provide genetic counseling for all germline testing with documented 3-generation family history.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

AR PASSEpolicy applies to

Germlinegenetic counseling required

Somaticno counseling required

HLAexcluded (no PA)

07/31/2025archival note

Coverage criteria and scope

Policy Summary

PayerCareSource

PolicyGenetic Testing and Counseling — Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization when required and provide genetic counseling for all germline testing with documented 3-generation family history.

SourceLink

On This Page

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Genetic testing coverage criteria

Coverage and requirements apply when testing is medically necessary and supported by medical necessity review:

Germline genetic testing counseling requirement: Genetic counseling is required for all germline genetic testing and must: enable informed decision making regarding testing purpose, management implications, heritable nature via 3-generation family history, range of possible results, benefits and risks; and be provided by a healthcare professional with relevant education and training.

From policy sections IV A and B

Somatic testing counseling: Somatic genetic testing does not require the genetic counseling described for germline testing.

Policy section V

Prior authorization and medical necessity review: Prior authorization may be required for both somatic and germline testing; CareSource will review requests for medical necessity using published MCG criteria when available and the Medical Necessity Determinations administrative policy.

Policy section D and IV

Proprietary panel testing requires evidence-based documentation per the Medical Necessity Determinations administrative policy; individual genetic tests may be requested separately if panels do not meet medical necessity requirements.

Policy section D III

When testing is covered

Medically necessary diagnostic or therapeutic genetic testing as determined by medical necessity review.

Medically necessary diagnostic or therapeutic genetic testing: Genetic testing for diagnostic or therapeutic purposes is covered when CareSource medical necessity review determines the test is medically necessary; testing may provide diagnostic and/or actionable therapeutic results that can impact patient management.

Background and policy D; uses MCG criteria when available

Genetic counseling for germline testing: For germline (inherited) testing, genetic counseling is required and must include interpretation of family and medical histories (including a 3-generation family history), education about natural history, inheritance, testing implications, management and prevention, discussion of benefits and risks, and provision of support and resources; counseling should be provided by a healthcare professional with relevant genetics training (certified genetic counselor or other qualified clinician when access is limited).

Background and IV A/B; counseling goals per NSGC described

Repeat germline testing is generally not necessary but may be considered in extraordinary circumstances (for example, due to changes in technology) with documented medical necessity.

Policy section VII

HLA typing exclusion: Human leukocyte antigen (HLA) typing is excluded from this genetic testing policy and does not require pre-authorization.

Policy section VI

Provider responsibilities, prior authorization, and documentation

Prior Authorization

Prior Authorization Required

Prior authorization may be required for genetic testing. CareSource will review requests for medical necessity. This includes both somatic and germline genetic testing and will be evaluated using published MCG criteria when available and the Medical Necessity Determinations administrative policy.

Applies to somatic and germline testing
CareSource medical necessity review per MCG and Medical Necessity Determinations policy
Requests governed by external MCG/InterQual guidelines with clear genetic counseling requirements are addressed by those guidelines

Step Therapy

Step therapy: No step therapy requirements are specified for genetic testing in this policy.

Documentation Required

Panels and Repeat Testing Documentation

Documentation for panels and repeat testing: Proprietary panel testing requires evidence-based documentation per the Medical Necessity Determinations administrative policy. Individual genetic tests may be requested separately when panels do not meet medical necessity. Repeat germline testing is generally not required but may be considered in extraordinary circumstances (e.g., significant change in technology) with appropriate medical necessity documentation.

Proprietary panels require evidence-based documentation per Medical Necessity Determinations policy
Individual tests may be requested separately if panel fails medical necessity
Repeat germline testing permitted only with extraordinary justification and documentation

Denial Risk

Medical Necessity and Coverage Controls

Medical necessity requirement: Services must meet medical necessity criteria and plan contract controls. Lack of documented medical necessity may result in denial of coverage. Medical Necessity reviews utilize published MCG criteria when available and the Medical Necessity Determinations administrative policy. If a conflict exists between this policy and the member's plan contract (Evidence of Coverage), the plan contract governs.

Documentation Required

Genetic Counseling Requirement (Germline Testing)

Genetic counseling is required for all germline genetic testing. Counseling must interpret family and medical histories (including a multigenerational family history) and address purpose of testing, inheritance, range of possible results, potential benefits and risks, and implications for management. Counseling is an integral component both before and after testing.

Required for all germline testing
Includes interpretation of family and medical histories (eg, a 3-generation family history)
Must cover purpose of testing, possible results, benefits/risks, and management implications

Note

Genetics Consultation and Counseling Providers

Genetics consultation recommendation: Testing may require consultation with medical genetics professionals. Genetic counseling should be provided by a certified genetic counselor or another qualified healthcare professional with education and training in relevant genetic issues when access to a genetic counselor is limited.

Consultation with medical genetics professionals may be required for complex cases
Counseling should be provided by a trained healthcare provider (certified genetic counselor preferred)

Member and test eligibility

Genetic testing services are covered when they meet medical necessity and associated policy requirements. 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 enable informed decision making and include discussion of testing purpose, management implications, the heritable nature of findings informed by a 3-generation family history, the range of possible results, and potential benefits and risks.

Somatic genetic testing does not require the germline-level genetic counseling described above. Prior authorization may be required for both somatic and germline testing, and CareSource will review requests for medical necessity using published MCG criteria when available and the Medical Necessity Determinations administrative policy. Proprietary panel testing requires evidence-based documentation and individual tests from a panel may be requested separately if the panel does not meet medical necessity requirements.

Key definitions

Genetic Testing (inv-11)

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

PurposeUsed to diagnose hereditary or acquired conditions and to inform clinical management when medically necessary.

Test typesIncludes both germline (inherited) and somatic (acquired) genetic testing.

Genetic Screening (inv-12)

DefinitionGenetic Screening: the process of testing a population for a genetic disease to identify a subgroup of people who either have the disease or the potential to pass it to offspring.

ScopePopulation-level testing to detect disease presence or carrier status, not necessarily diagnostic for individuals.

Use caseMay be used for public health programs, newborn screening, or targeted population screening initiatives.

HLA Typing (inv-13)

DefinitionHLA Typing: a test used to match patients and donors for bone marrow or cord blood transplants.

Policy noteHLA typing is not part of the genetic testing policy and does not require pre-authorization under this policy.

Typical usePrimarily used to ensure compatibility between donor and recipient in hematopoietic cell transplantation.

Inherited Genetic Variant (inv-14)

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

ImplicationVariants present in the germline can confer inherited disease risk and have lifelong relevance for the individual and family members.

Testing relevanceGermline testing requires genetic counseling as specified in the policy to inform about heritable nature and family implications.

Somatic Gene Variant (inv-15)

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

Clinical relevanceSomatic variants are typically relevant to acquired diseases such as cancer and may guide targeted therapies.

Counseling requirementSomatic genetic testing does not require the germline genetic counseling described for inherited testing.

Policy revision history

2024-07-03revision

Clarified genetic counseling requirements and added language regarding MCG; approved at Committee.

2024-04-10review

Review updated references and approved at Committee.

2023-05-10review

Annual review rephrased genetic counseling process; approved at Committee.

2022-05-25revision

Annual review updated background, definitions, and references and re-organized criteria; approved at Committee.

2020-12-17original_issue

Policy originally issued as a new policy.

2025-07-31archivalLatest

Policy archived and is no longer active as of this date.

OpenPayer