CurrentCareSourcePolicy N/A

Genetic Testing and Counseling - Arkansas PASSE

Governs prior authorization, 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 change

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when required and ensure genetic counseling (including a 3‑generation family history) is provided for all germline genetic testing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

genetic counselingpolicy requirement

prior auth may be requiredauthorization note

HLA excludedexplicit exclusion

MCG & AR statutesguidance sources

Coverage and Medical Necessity Criteria

Coverage criteria

Covered when reviewed and approved per medical necessity determinations and MCG criteria as applicable:

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

Proprietary panels require evidence-based documentation; individual tests may be requested separately if panels do not meet medical necessity.

Germline testing counseling requirement: 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, and must enable informed decision making including a 3-generation family history and discussion of possible results and risks.

Somatic testing does not require this genetic counseling.

HLA typing exclusion:

Policy Summary

PayerCareSource

PolicyGenetic Testing and Counseling - Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when required and ensure genetic counseling (including a 3‑generation family history) is provided for all germline genetic testing.

SourceLink

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Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization may be required for genetic testing (both somatic and germline). Lack of required prior authorization when prior authorization is required for genetic testing may result in claim denial. Providers should verify prior authorization requirements before ordering tests.

Applies to somatic and germline genetic testing
Denial risk if required prior authorization not obtained

Documentation Required

Medical Necessity Review

CareSource will review genetic testing requests for medical necessity using published MCG criteria when available and the Medical Necessity Determinations administrative policy. Proprietary panel testing requires evidence-based documentation per the Medical Necessity Determinations administrative policy; individual genetic tests may be requested separately for panels that do not meet medical necessity.

MCG criteria and Medical Necessity Determinations policy guide reviews
Proprietary panels need evidence-based justification

Documentation Required

Genetic Counseling Requirement

Genetic counseling is required for all germline genetic testing and must be provided by a healthcare professional with relevant education and training in genetic issues relevant to the tests under consideration. Counseling must enable informed decision-making by the member (purpose of testing, potential management implications, heritable nature with a 3‑generation family history, range of possible results, and potential benefits/risks such as psychological, social, and economic). Somatic genetic testing does not require the genetic counseling described above.

Required for all germline genetic testing
May be provided by appropriately trained healthcare professionals
Somatic testing exempt from this counseling requirement

Note

Provider Actions — Not Otherwise Specified

Providers: The document does not specify additional provider action details beyond prior authorization and documentation requirements. Verify prior authorization and include evidence-based documentation and genetic counseling (for germline tests) where applicable to avoid denial.

Provider-specific actions beyond prior authorization are not specified in this policy
Obtain prior authorization when required and supply documentation to support medical necessity
Ensure genetic counseling is documented for germline testing

Documentation Required

Proprietary Panel Testing

Proprietary panels: Evidence-based documentation per the Medical Necessity Determinations policy is required. If a panel does not meet medical necessity criteria, CareSource may request individual test justification or deny coverage.

Proprietary panel testing requires evidence-based support
Individual tests may be requested separately if panel fails medical necessity

Note

Scope and Repeat Testing

HLA typing is outside the scope of this genetic testing policy and does not require prior authorization under this policy. Most inherited germline testing is typically performed once in a lifetime; repeat germline testing may be considered only in extraordinary circumstances with appropriate medical necessity documentation.

HLA typing not covered by this policy — no preauthorization required
Repeat germline testing allowed only with documented extraordinary justification

Definitions

Genetic Screening — inv-11

DefinitionGenetic screening is 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 affected individuals or carriers within a broader population.

ScopeApplied at a population level rather than targeted diagnostic testing for individuals.

Genetic Testing — inv-12

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

Use casesDiagnostic confirmation, carrier detection, or identification of acquired (somatic) changes relevant to treatment.

Result typesMay detect gene, chromosomal, or protein changes that inform diagnosis or management.

HLA Typing — inv-13

DefinitionHuman Leukocyte Antigen (HLA) typing is 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 preauthorization.

Clinical usePrimarily used for donor–recipient compatibility in transplant settings.

Inherited Genetic Variant — inv-14

DefinitionAn inherited genetic variant is a DNA sequence change passed from a parent to offspring (germline).

ImplicationGermline variants can have lifelong implications and inform inherited disease risk and family counseling.

Counseling requirementGenetic counseling is required for all germline testing and must include a 3-generation family history to inform heritable nature and risk assessment.

Precision Medicine — inv-15

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

ApplicationUses genetic information to guide therapy selection and optimize treatment effectiveness.

Relation to testingPharmacogenomic results are a common precision medicine application.

Somatic Gene Variant — inv-16

DefinitionA somatic gene variant is a DNA sequence change that is not inherited from a parent but is acquired during a person's life.

Clinical relevanceSomatic variants are often detected in tumors and can inform targeted therapies.

Policy implicationSomatic genetic testing may require prior authorization and medical necessity review but does not require the germline-specific genetic counseling described in the policy.

OpenPayer

Genetic Testing and Counseling - Arkansas PASSE

Coverage and Medical Necessity Criteria

Coding and Test Frequency

Provider Requirements and Prior Authorization

Definitions

Background and Rationale

Eligibility and Counseling Requirements

Tests Not Covered