CurrentCareSourcePolicy N/A

Genetic Testing and Counseling — Arkansas PASSE

Defines CareSource coverage stance, authorization and genetic counseling requirements for germline and somatic genetic testing for Arkansas PASSE members, and references use of MCG and the Medical Necessity Determinations administrative policy.

Policy Summary

PayerCareSource

PolicyGenetic Testing and Counseling — Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when required and document medical necessity and genetic counseling for germline tests per MCG and the Medical Necessity Determinations policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

genetic counselingpolicy requirement

prior authauthorization possible

MCGmedical necessity source

HLA excludedscope exclusion

08/01/2025effective date

Coverage Criteria for Genetic & Molecular Testing

Medical necessity and counseling criteria

Covered when medical necessity is established per MCG and the Medical Necessity Determinations administrative policy:

General medical necessity review: CareSource will review genetic testing requests (somatic and germline) for medical necessity using published MCG criteria when available and the Medical Necessity Determinations administrative policy.

MCG guidance supersedes this policy where applicable

Proprietary panel evidence: 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.

Germline genetic counseling: Genetic counseling is required for all germline genetic testing and must include informed decision-making elements (purpose of testing; management implications; heritable nature informed by a 3-generation family history; range of possible results; potential benefits and risks, including psychological, social, and economic considerations). Counseling must be provided by a healthcare professional with education and training in genetic issues relevant to the tests under consideration.

Policy Summary

PayerCareSource

PolicyGenetic Testing and Counseling — Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when required and document medical necessity and genetic counseling for germline tests per MCG and the Medical Necessity Determinations policy.

SourceLink

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Provider Responsibilities and Authorization

Prior Authorization

Prior authorization may be required

Prior authorization may be required for somatic and germline genetic testing. CareSource will review requests for medical necessity using published MCG criteria when available and the Medical Necessity Determinations administrative policy. Requests that lack required medical necessity documentation or do not meet MCG/administrative policy criteria may be denied.

Applies to somatic and germline genetic testing
CareSource uses published MCG criteria and the Medical Necessity Determinations administrative policy

Denial Risk

Authorization and denial risk

CareSource may deny authorization or request additional information if required documentation is missing, insufficient, or if testing does not meet MCG or administrative medical necessity criteria. Proprietary panel testing that lacks evidence-based documentation may be denied; individual tests from a panel may be requested instead per Medical Necessity Determinations.

Lack of documentation or failure to meet MCG/administrative policy = denial risk
Proprietary panels require evidence-based documentation; otherwise individual test requests may be considered

Documentation Required

Documentation required for panels and repeats

Proprietary panel testing and repeat germline testing require supporting documentation demonstrating medical necessity. Repeated germline testing is generally not covered except in extraordinary circumstances (eg, substantive changes in technology) and must include documentation explaining the clinical rationale for repeat testing. Evidence-based documentation should follow the Medical Necessity Determinations administrative policy.

Proprietary panels: require evidence-based documentation per Medical Necessity Determinations
Repeat germline testing: allowed only with documentation of extraordinary circumstances (eg, technology change)

Documentation Required

Pre- and post-test genetic counseling required for all germline genetic testing

Pre-test and post-test genetic counseling is required for all germline genetic testing to enable informed decision making (purpose of testing, implications for management, heritable nature using a 3-generation family history, possible results, benefits and risks, and alternatives). Counseling must be provided by a healthcare professional with education and training in genetic issues relevant to the tests under consideration. Somatic genetic testing does not require this genetic counseling.

Germline testing: pre- and post-test counseling required
Counseling content: purpose, implications, heritability (3-generation family history), result range, benefits/risks, alternatives
Counselor qualifications: healthcare professional trained in relevant genetic issues
Somatic testing: genetic counseling not required

Note

Ordering/provider qualifications

The policy does not specify exact ordering/provider types for genetic testing beyond requiring counseling by a qualified healthcare professional. Genetic counseling may be provided by certified genetic counselors or other qualified professionals with appropriate education and training in genetic issues relevant to the test.

Ordering/provider qualifications: not precisely specified in policy
Genetic counseling may be delivered by certified genetic counselors or other qualified professionals

Definitions

Genetic Screening (definition)

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.

PurposeIdentify individuals with or at risk for a genetic disease to enable further diagnostic evaluation or intervention.

Population focusApplies to screening of populations or subgroups rather than diagnostic testing of a single symptomatic individual.

Genetic Testing (definition)

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.

ScopeIncludes tests for inherited (germline) and acquired (somatic) conditions.

Use casesUsed for diagnosis, confirmation, and clinical decision-making based on identified genetic changes.

Somatic Gene Variant (definition)

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

Clinical implicationRepresents acquired mutations often relevant to tumor genetics and targeted therapies.

DistinctionNot passed to offspring (contrasts with inherited/germline variants).

HLA Typing (definition)

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

Primary useDonor–recipient compatibility assessment for hematopoietic stem cell and cord blood transplantation.

Policy noteHLA typing is handled outside this genetic testing policy and does not require pre-authorization under this policy.

OpenPayer

Genetic Testing and Counseling — Arkansas PASSE

Coverage Criteria for Genetic & Molecular Testing

Eligibility and Counseling Requirements

Provider Responsibilities and Authorization

Definitions

Background

Services Not Covered / Policy Exclusions