Centene hereditary cancer genetic testing Policy Update

Coverage Criteria and Medical Necessity

inv-22: PTEN Sequencing and Deletion/Duplication Analysis (Cowden syndrome/PHTS)

PTEN (Cowden syndrome / PTEN hamartoma tumor syndrome) — Covered when ALL of the following are met:

ALL of the following

The member/enrollee has a personal history of any of the following: Bannayan Riley-Ruvalcaba syndrome; adult Lhermitte-Duclos disease (cerebellar dysplastic gangliocytoma); autism-spectrum disorder with macrocephaly; at least two biopsy-proven trichilemmomas;
The member/enrollee meets clinical criteria for Cowden syndrome/PTEN hamartoma tumor syndrome (CS/PHTS), defined by one or more of: macrocephaly (>=97th percentile); Lhermitte-Duclos disease; gastrointestinal hamartomas or ganglioneuromas plus at least two of breast cancer, endometrial cancer, follicular thyroid cancer, macular pigmentation of the glans penis, mucocutaneous lesions (eg, biopsy-proven trichilemmoma, multiple palmoplantar keratoses, extensive oral papillomatosis), or other listed supportive features;
OR the member/enrollee has at least two of the following: breast cancer; endometrial cancer; follicular thyroid cancer; multiple gastrointestinal hamartomas or ganglioneuromas; macrocephaly (>=97th percentile); macular pigmentation of the glans penis; mucocutaneous lesions — with at least three additional supportive features (autism spectrum disorder, colon cancer, esophageal glycogenic acanthosis, lipomas, intellectual disability, papillary thyroid cancer variants, thyroid structural lesions, renal cell carcinoma, single GI hamartoma or ganglioneuroma, testicular lipomatosis, vascular anomalies);
OR the member/enrollee has macrocephaly plus one of: breast cancer, endometrial cancer, follicular thyroid cancer, multiple GI hamartomas or ganglioneuromas, or other listed features;
Targeted PTEN variant analysis is covered when there is a first-/second-degree relative with a known PTEN P/LP variant or when a PTEN P/LP variant was identified on tumor profiling in the member and germline confirmation has not yet been performed.

inv-31: MEN1 targeted and sequencing criteria (targeted)

MEN1 targeted variant analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has a close relative with a known pathogenic or likely pathogenic variant in MEN1;
A pathogenic or likely pathogenic variant in MEN1 was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-31: MEN1 targeted and sequencing criteria (sequencing)

MEN1 sequencing and/or deletion/duplication analysis — Covered when ALL of the following are met:

ALL of the following

The member/enrollee has a personal history of at least two of the following: duodenal or pancreatic neuroendocrine tumor; primary hyperparathyroidism; pituitary adenoma; foregut (bronchial, thymic, or gastric) carcinoid;
OR the member/enrollee has a personal history of one of the above and a close relative with at least one of the above;
Sequencing/deletion-duplication testing is investigational for other indications.

inv-18: ATM and CHEK2 Targeted and Sequencing Analysis (targeted)

ATM and CHEK2 targeted analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has a close relative with a known pathogenic or likely pathogenic variant in ATM or CHEK2;
A pathogenic or likely pathogenic variant in ATM or CHEK2 was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-18: ATM and CHEK2 Targeted and Sequencing Analysis (sequencing)

ATM and/or CHEK2 sequencing and deletion/duplication analysis — Coverage statement:

ALL of the following

As a stand-alone germline sequencing and/or deletion/duplication test for ATM and/or CHEK2, sequencing is considered investigational (not covered);
ATM mRNA sequencing for interpretation of VUS is considered investigational when billed in addition.

inv-19: MLH1, MSH2, MSH6, PMS2, EPCAM Targeted Analysis

Lynch syndrome (MLH1, MSH2, MSH6, PMS2, EPCAM) — Targeted variant analysis covered when ANY of the following are met:

ANY of the following

The member/enrollee has a blood relative with a known pathogenic or likely pathogenic variant in MLH1, MSH2, MSH6, PMS2, or EPCAM;
A pathogenic or likely pathogenic variant in MLH1, MSH2, MSH6, PMS2, or EPCAM was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-19: MLH1, MSH2, MSH6, PMS2, EPCAM Sequencing and/or Deletion/Duplication Analysis

Lynch syndrome sequencing and/or deletion/duplication analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has a Lynch syndrome-related cancer and the tumor shows evidence of mismatch repair (MMR) deficiency (MSI or loss of MMR protein expression);
The member/enrollee has a diagnosis of a Lynch syndrome-related cancer AND any of: diagnosed before age 50; diagnosed at any age with an additional Lynch-related cancer; diagnosed at any age with one or more first- or second-degree relatives diagnosed before age 50 with a Lynch-related cancer; diagnosed at any age with two or more first- or second-degree relatives with Lynch-related cancers (any ages);
The member/enrollee has a family history meeting specified relatives criteria consistent with Lynch syndrome;
The member/enrollee has a 5% or greater risk of Lynch syndrome based on MMRpro, PREMM5, MMRpredict, or has colorectal/endometrial cancer with a PREMM5 score >=2.5%.

inv-20: BAP1 Targeted Variant Analysis

BAP1 tumor predisposition syndrome — Targeted variant analysis is covered when ANY of the following are met:

ANY of the following

The member/enrollee has a close relative with a known pathogenic or likely pathogenic variant in BAP1;
A pathogenic or likely pathogenic variant in BAP1 was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-20: BAP1 Sequencing and/or Deletion/Duplication Analysis

BAP1 sequencing and/or deletion/duplication analysis — Covered when ANY of the following are met:

ANY of the following

Personal history of two or more of the following: BAP1-inactivated melanocytic tumors (atypical spitz tumor), uveal melanoma, malignant mesothelioma, renal cell carcinoma, hepatocellular carcinoma, cholangiocarcinoma, meningioma;
Personal history of one of the tumors above AND a cutaneous melanoma or basal cell carcinoma;
Personal history of one of the tumors above AND a first- or second-degree relative with any of the listed tumors;
Diagnosis of cutaneous melanoma or basal cell carcinoma AND a first- or second-degree relative with one of the listed BAP1-associated tumors.

inv-21: FLCN Targeted Variant Analysis

FLCN (Birt-Hogg-Dube syndrome) — Targeted variant analysis covered when ANY of the following are met:

ANY of the following

The member/enrollee has a first- or second-degree relative with a known pathogenic or likely pathogenic variant in FLCN;
A pathogenic or likely pathogenic variant in FLCN was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-21: FLCN Sequencing and/or Deletion/Duplication Analysis

FLCN sequencing and/or deletion/duplication analysis — Covered when ALL of the following are met:

ALL of the following

The member/enrollee has a personal history of any of: five or more fibrofolliculomas/trichodiscomas with at least one confirmed histologically; multiple lung cysts of unknown cause with or without pneumothorax; renal cancer diagnosed before age 50; multifocal or bilateral renal cancer; renal tumors with mixed chromophobe/oncocytic, clear cell, or papillary histology; oncocytoma; angiomyolipoma; or a first-degree relative with BHDS who has not had genetic testing or testing results unknown;
Sequencing/deletion-duplication testing is investigational for other indications.

inv-24: APC / MUTYH targeted variant analysis

APC and/or MUTYH targeted variant analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has a family history of a known pathogenic or likely pathogenic variant in APC or MUTYH;
A pathogenic or likely pathogenic variant in APC or MUTYH was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-25: APC / MUTYH sequencing and deletion/duplication

APC and/or MUTYH sequencing and/or deletion/duplication analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has a history of 10 or more cumulative adenomas;
Congenital hypertrophy of the retinal pigment epithelium (CHRPE);
Desmoid tumor, hepatoblastoma, cribriform-morular variant of papillary thyroid cancer, a clinical diagnosis of serrated-polyposis with at least some adenomas (per defined polyp thresholds);
Duodenal cancer or duodenal adenomas;
Sequencing/deletion-duplication testing is investigational for other indications;

inv-26: CDKN2A targeted analysis

CDKN2A targeted analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has a close relative with a known pathogenic or likely pathogenic variant in CDKN2A;
A CDKN2A pathogenic or likely pathogenic variant was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-26: CDKN2A sequencing criteria

CDKN2A sequencing and/or deletion/duplication analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has had three or more invasive cutaneous melanomas;
The member/enrollee has had pancreatic adenocarcinoma;
The member/enrollee has had at least one cutaneous melanoma AND at least two close relatives with pancreatic cancer or cutaneous melanoma on the same side of the family;

inv-27: CDH1 targeted variant analysis

CDH1 targeted variant analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee is 18 years or older AND has a close relative with a known pathogenic or likely pathogenic variant in CDH1;
A pathogenic or likely pathogenic variant in CDH1 was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-27: CDH1 sequencing and deletion/duplication

CDH1 sequencing and/or deletion/duplication analysis — Covered when ALL of the following are met:

ALL of the following

The member/enrollee is 18 years or older;
The member/enrollee meets at least one of: diffuse gastric cancer diagnosed before age 50; diffuse gastric cancer at any age with Maori ancestry; diffuse gastric cancer at any age with personal or family history of cleft lip/palate; bilateral lobular breast cancer diagnosed before age 70; personal or family history of diffuse gastric cancer and lobular breast cancer (one diagnosed before age 70); two cases of gastric cancer in the family with at least one confirmed diffuse gastric cancer; two cases of lobular breast cancer in family members before 50 years of age;

inv-28: SMAD4 / BMPR1A targeted variant analysis

Juvenile polyposis syndrome (SMAD4 / BMPR1A) — Targeted variant analysis covered when ANY of the following are met:

ANY of the following

The member/enrollee has a blood relative with a known pathogenic or likely pathogenic variant in SMAD4 and/or BMPR1A;
A pathogenic or likely pathogenic variant in SMAD4 and/or BMPR1A was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-28: SMAD4 / BMPR1A sequencing criteria (JPS)

SMAD4 and/or BMPR1A sequencing and/or deletion/duplication analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has five or more juvenile polyps in the colon;
The member/enrollee has multiple juvenile polyps throughout the GI tract;
The member/enrollee has a family history of juvenile polyposis syndrome (JPS).

inv-29: FH targeted variant analysis

FH (hereditary leiomyomatosis and renal cell cancer, HLRCC) — Targeted variant analysis covered when ANY of the following are met:

ANY of the following

The member/enrollee has a first- or second-degree relative with a known pathogenic or likely pathogenic variant in FH;
A pathogenic or likely pathogenic variant in FH was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-29: FH sequencing and deletion/duplication

FH sequencing and/or deletion/duplication analysis — Covered when BOTH of the following are met:

ALL of the following

The member/enrollee is 18 years or older (age criterion removed in some surveillance contexts per guideline updates may not apply);
The member/enrollee has at least one of: cutaneous leiomyomata; uterine leiomyomata (fibroids); or renal cell carcinoma.

inv-30: TP53 targeted variant analysis

TP53 targeted variant analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has a close relative with a known pathogenic or likely pathogenic variant in TP53;
A pathogenic or likely pathogenic variant in TP53 was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-30: TP53 sequencing and deletion/duplication (LFS)

TP53 sequencing and/or deletion/duplication analysis — Covered when ANY of the following are met (classic and Chompret/LFS criteria):

ANY of the following

Classic LFS family criteria (individual with sarcoma before 45, a first-degree relative with cancer before 45, and an additional first- or second-degree relative with cancer before 45 or a sarcoma at any age);
Chompret criteria (eg, tumor from LFS spectrum before 46 and at least one first- or second-degree relative with LFS tumor before 56 or multiple primaries; multiple tumors with two in LFS spectrum with initial cancer before 46; adrenocortical carcinoma, choroid plexus carcinoma, or embryonal rhabdomyosarcoma at any age; breast cancer before 31);
Personal or family history of pediatric hypodiploid acute lymphoblastic leukemia;

inv-34: RET targeted variant analysis

RET targeted variant analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has a close relative with a known pathogenic or likely pathogenic variant in RET;
A pathogenic or likely pathogenic variant in RET was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-34: RET sequencing and deletion/duplication

RET sequencing and/or deletion/duplication analysis — Covered when ALL of the following are met:

ALL of the following

The member/enrollee has a diagnosis of any of: medullary thyroid cancer; adrenal pheochromocytoma; parathyroid adenoma or hyperplasia;
OR the member/enrollee has a first-degree relative meeting at least one of the above criteria and that relative has not previously undergone RET sequencing/deletion-duplication analysis.

inv-35: PTCH1 and SUFU targeted variant analysis

PTCH1 and SUFU targeted variant analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has a close relative with a known pathogenic or likely pathogenic variant in PTCH1 or SUFU;
A pathogenic or likely pathogenic variant in PTCH1 or SUFU was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-35: PTCH1 and SUFU sequencing and deletion/duplication

PTCH1 and SUFU sequencing and/or deletion/duplication analysis — Covered when ALL of the following are met:

ALL of the following

The member/enrollee has a personal history meeting defined NBCCS (Gorlin syndrome) clinical features such as at least two major features (lamellar calcification of the falx, jaw keratocyst, palmar/plantar pits, multiple basal cell carcinomas or BCC before 30) or combinations of listed minor features;
Sequencing/deletion-duplication testing is investigational for other indications.

inv-36: Hereditary paraganglioma/pheochromocytoma targeted analysis

Hereditary paraganglioma/pheochromocytoma (PGL/PCC) targeted variant analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has a close relative with a known pathogenic or likely pathogenic variant in MAX, SDHA, SDHAF2, SDHB, SDHC, SDHD, or TMEM127;
A pathogenic or likely pathogenic variant in one of these genes was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-36: Hereditary paraganglioma/pheochromocytoma sequencing

Hereditary paraganglioma/pheochromocytoma sequencing and/or deletion/duplication analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has a diagnosis of pheochromocytoma or paraganglioma;
The member/enrollee has clear indications such as gastrointestinal stromal tumor (GIST) or renal cell cancer associated in family history;
The member/enrollee has a close relative with paraganglioma or pheochromocytoma.

inv-37: STK11 targeted analysis

STK11 (Peutz-Jeghers syndrome) — Targeted variant analysis covered when ANY of the following are met:

ANY of the following

The member/enrollee has a blood relative with a known pathogenic or likely pathogenic variant in STK11;
A pathogenic or likely pathogenic variant in STK11 was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-37: STK11 sequencing and deletion/duplication (PJS)

STK11 sequencing and/or deletion/duplication analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has at least two histologically confirmed Peutz-Jeghers-type hamartomatous polyps of the GI tract;
The member/enrollee has mucocutaneous pigmentation of the mouth, lips, nose, eyes, genitalia, or fingers;
The member/enrollee has a family history of Peutz-Jeghers syndrome (PJS).

inv-63: RB1 targeted analysis

RB1 targeted variant analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has a close relative with a known pathogenic or likely pathogenic variant in RB1;
A pathogenic or likely pathogenic variant in RB1 was identified by tumor profiling in the member and germline analysis has not yet been performed.

inv-63: RB1 sequencing and deletion/duplication

RB1 sequencing and/or deletion/duplication analysis — Covered when ANY of the following are met:

ANY of the following

The member/enrollee has a diagnosis of retinoblastoma in one or both eyes;
The member/enrollee has a close relative with retinoblastoma in one or both eyes.

inv-69: BRCA1/BRCA2 sequencing and/or deletion/duplication analysis (updated)

BRCA1 and BRCA2 sequencing and/or deletion/duplication analysis — Covered when ANY of the following are met (updated criteria aligned with NCCN/ASCO/SSO):

ANY of the following

The member/enrollee is 18 years or older and has a personal history of: male breast cancer; triple-negative breast cancer; breast cancer diagnosed at age 65 or younger; epithelial ovarian, fallopian tube, or primary peritoneal cancer; exocrine pancreatic or ampullary cancer; metastatic prostate cancer; high- or very-high-risk group prostate cancer; intermediate-risk prostate cancer with intraductal/cribriform histology; multiple primary breast cancers;
The member/enrollee has breast cancer and any of: Ashkenazi Jewish ancestry; a close relative with breast cancer at or under age 50, male breast cancer, ovarian cancer, pancreatic cancer, or prostate cancer that is metastatic or high/very-high risk; three or more total diagnoses of breast and/or prostate cancer in the same side of the family including the member;
The member/enrollee has a first- or second-degree relative meeting any of the above criteria;

inv-66: Therapy-informing germline testing

Therapy-informing germline testing — Covered when ALL of the following are met:

ALL of the following

Germline testing is being performed to inform systemic therapy decisions (for example: PARP inhibitor eligibility for metastatic breast cancer or adjuvant olaparib for high-risk HER2-negative breast cancer);
The gene/test requested is relevant to the therapeutic decision and is supported by guidelines;
Testing follows the targeted vs broader testing logic: if clinical/risk factors meet criteria for broader (full gene or panel) testing, broader testing should be performed rather than targeted analysis.

Procedure and Diagnosis Codes

Covered CPT CodesCPTCovered

81401	Targeted genomic sequence analysis (e.g., single gene or specific variants) - example mapping for MUTYH targeted analysis
81212	BRCA1 and BRCA2 targeted analysis — Ashkenazi Jewish founder variants
81215	BRCA1 targeted variant analysis
81217	BRCA2 targeted variant analysis
81162	BRCA1 and BRCA2 sequencing — full gene (example panel codes)
81163	BRCA1 and BRCA2 sequencing — full gene (example panel codes)
81432	Pan-cancer hereditary cancer susceptibility panel — CPT example
81433	Pan-cancer hereditary cancer susceptibility panel — CPT example
81435	Hereditary colorectal cancer panel — CPT example
81436	Hereditary colorectal cancer panel — CPT example

1–10 of 31

1/4

Covered HCPCS/Local CodesHCPCSCovered

S3840	Laboratory multigene sequencing panel, hereditary cancer panel (proprietary / local code example)
S3841	Laboratory multigene sequencing panel, hereditary cancer panel add-on (proprietary / local code example)
S3842	Laboratory targeted variant analysis, hereditary cancer panel (proprietary / local code example)

Unlisted / Proprietary / PLA and Category III (examples)mixed

0134U	Proprietary mRNA sequencing for VUS interpretation (example)
0130U	Proprietary mRNA sequencing for colorectal panel (example)
0138U	BRCA1/2 mRNA sequencing for VUS interpretation (example)
0474U	GeneticsNow Comprehensive Germline Panel (example CPT/PLA)

Ordering, Prior Authorization, and Documentation

Prior Authorization

Prior authorization — coding examples

Prior authorization may be required for the hereditary cancer panels and single-gene CPT/proprietary codes referenced in the policy; codes listed in the policy are examples and inclusion does not guarantee coverage. Providers should verify payer PA rules and submit the specific test code(s) when requesting authorization.

Examples of panel CPT codes: 81432, 81433 (pan-cancer panels) and proprietary codes (e.g., 0474U).
Inclusion/exclusion of codes in the policy does not guarantee coverage; reference current coding guidance prior to claim submission.

Prior Authorization

Prior authorization may apply for Lynch-related gene testing

Prior authorization may apply when ordering MLH1/MSH2/MSH6/PMS2/EPCAM sequencing or deletion/duplication analyses; submit the specific CPT codes and documentation per payer rules.

MLH1/MSH2/MSH6/PMS2/EPCAM sequencing/del-dup examples mapped to codes such as 81292/81294/81295/81297/81298/81300/81317/81319/81403.

Investigational and Not Covered Indications

Panel tests should be constructed to include only genes with an established, evidence-based association to the condition being evaluated. The policy discourages inclusion of genes without known disease association on hereditary cancer panels because larger, less-focused panels increase the likelihood of detecting variants of uncertain significance and may lack demonstrated clinical utility. When a panel includes genes without a known association to the cancer type under evaluation, use of those panel components is implied to be not covered unless clinical justification consistent with the policy is provided.

Each panel and gene-specific test included in this policy is covered only for the clinical indications explicitly listed in the corresponding section. Tests or multi-gene panels used for indications that do not meet the enumerated medical necessity criteria in their gene- or panel-specific sections are considered investigational and therefore not covered.

Targeted mRNA sequencing assays (proprietary PLA/UC codes such as 0134U, 0130U, 0162U, 0133U and related RNA-insight codes) when billed as an additional procedure to interpret variants of uncertain significance are considered investigational. These add-on mRNA analyses are typically considered part of laboratory follow-up or quality processes and lack proven utility as separately billed services in this context.

Routine population screening for BRCA1/BRCA2 in individuals without a personal or family history or ancestry associated with BRCA1/2 pathogenic variants is not recommended. The USPSTF advises against routine risk assessment, genetic counseling, or genetic testing for women whose personal or family history or ancestry is not associated with potentially harmful BRCA1/2 variants; population screening outside guideline-based indications is therefore not supported by this policy.

The policy discourages inclusion of genes on cancer panels when there is no established association between the gene and the specific cancer (for example, adding genes without known gastric‑cancer association to a gastric cancer panel). Such panel content is not consistent with the policy’s requirement that panels include a defined minimum gene set tied to the syndrome or cancer type being evaluated, and additions lacking known relevance are discouraged and implied not covered.

Definitions and Key Terms

Targeted mutation testing — definition

DefinitionAnalysis of a single pathogenic or likely pathogenic (P/LP) variant in one gene, typically used when a known familial P/LP variant exists or when a somatic P/LP variant on tumor profiling prompts germline confirmation.

When appropriateUsed for targeted familial testing when a close blood relative has a known P/LP variant.

Tumor-derived triggerMay be used to confirm a P/LP variant identified by somatic tumor profiling when clinical/family history supports possible germline origin.

Not first-line when broader testing indicatedIf clinical history meets criteria for full gene or multi-gene panel testing, targeted testing is not appropriate as first-line.

Multi-gene panel — definition

Definition

Background and Rationale

Germline genetic testing detects inherited pathogenic or likely pathogenic variants that confer increased cancer susceptibility and can inform personalized screening, prevention, and treatment strategies. Testing options include single‑gene assays for a known familial variant, targeted variant analyses, and multi‑gene panels (cancer‑specific or pan‑cancer). Panel selection should consider patient preference, gene penetrance, and the higher likelihood of variants of uncertain significance with larger panels; professional guidance (NSGC) supports use of multigene panels when clinically warranted and when analytic and clinical validity and clinical utility are established.

Documentation expectations and rationale updates emphasize use of prior‑probability risk models, integration of tumor profiling results that may trigger germline testing, and the role of genetic counseling. Providers should document clinical and family history, prior‑probability model scores when used (examples: Tyrer‑Cuzick, BRCApro, CanRisk, PREMM5), and tumor profiling evidence when a somatic pathogenic/likely pathogenic variant prompts confirmatory germline testing. Background guidance also highlights referral to variant reclassification programs or RNA studies where appropriate for VUS evaluation.

Germline testing may have therapy‑informing implications and the policy reflects expanded panel inclusions and tumor‑type indications where treatment decisions are impacted (for example, inclusion of PALB2 and BRCA1/2 in considerations for metastatic prostate cancer and PARP inhibitor eligibility). When germline results affect systemic therapy selection, ordering and coverage should follow the syndrome‑ and gene‑specific criteria in this policy.

OpenPayer

Concert Genetic Testing: Hereditary Cancer Susceptibility

Coverage Criteria and Medical Necessity

Procedure and Diagnosis Codes

Ordering, Prior Authorization, and Documentation

Investigational and Not Covered Indications

Definitions and Key Terms

Background and Rationale