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    v1.0.30
    OpenPayerPolicy UpdatesGenetic & Molecular TestingColorado Rocky Mountain Hereditary Coverage | Open…
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    CurrentColorado Rocky Mountain Health PlansPolicy CSNCT0049.01

    Genetic Testing for Hereditary Cancer (for North Carolina Only)

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    This policy governs hereditary cancer genetic testing for members in North Carolina. Medical necessity and coverage criteria are delegated to the North Carolina Medicaid Division of Health Benefits Clinical Coverage Policy, Laboratory Services, 1S-9.

    Policy Summary
    PayerColorado Rocky Mountain Health Plans
    PolicyGenetic Testing for Hereditary Cancer (for North Carolina Only)
    Policy CodePolicy CSNCT0049.01
    Change TypeNew medical policy
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionEnsure the medical record contains legible documentation supporting medical necessity for the requested genetic testing, including relevant history, examination findings, and pertinent diagnostic results.
    SourceLink

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    POLICY UPDATE CHANGES

    The policy was issued as a new medical policy effective October 1, 2026.

    NCApplicable state
    1S-9Governing policy
    20Applicable codes
    CLIALaboratory framework

    Medical Necessity and Coverage Criteria

    Medical necessity criteria

    Refer to the North Carolina Medicaid Division of Health Benefits Clinical Coverage Policy, Laboratory Services, 1S-9, for medical necessity clinical coverage criteria.

    External North Carolina Medicaid criteria: Medical necessity and coverage are determined under the North Carolina Medicaid Clinical Coverage Policy, Laboratory Services, 1S-9: Genetic Testing for Diagnosis and Treatment.

    This policy does not reproduce the underlying clinical criteria.

    FDA approval alone is not a basis for coverage. Coverage is determined by the applicable medical necessity and coverage requirements, not solely by FDA approval or clearance.

    Applicable Codes

    Applicable CodesCPT
    0138UBRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) mRNA sequence analysis (List separately in addition to code for primary procedure)
    81162BRCA1, BRCA2 (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (i.e., detection of large gene rearrangements)
    81164BRCA1, BRCA2 (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis
    0103UHereditary ovarian cancer (e.g., hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with mRNA analytics to resolve variants of unknown significance when indicated (24 genes [sequencing and deletion/duplication], EPCAM [deletion/duplication only])
    0129UHereditary breast cancer-related disorders (e.g., hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and deletion/duplication analysis panel (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, and TP53)
    0130UHereditary colon cancer disorders (e.g., Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, and TP53) (List separately in addition to code for primary procedure)
    0133UHereditary prostate cancer-related disorders, targeted mRNA sequence analysis panel (11 genes) (List separately in addition to code for primary procedure)
    0134UHereditary pan cancer (e.g., hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) (List separately in addition to code for primary procedure)
    0162UHereditary colon cancer (Lynch syndrome), targeted mRNA sequence analysis panel (MLH1, MSH2, MSH6, PMS2), EPCAM, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions
    0474UHereditary pan-cancer (e.g., hereditary sarcomas, hereditary endocrine tumors, hereditary neuroendocrine tumors, hereditary cutaneous melanoma), genomic sequence analysis panel of 88 genes with duplications/deletions using next-generation sequencing (NGS), Sanger sequencing, blood or saliva, reported as positive or negative for germline variants, each gene
    1–10 of 20
    1/2

    Documentation Requirements

    Documentation Required

    Medical Necessity Documentation

    Maintain legible medical-record documentation that fully supports the medical necessity of the requested genetic testing. Records may be requested to assess clinical-criteria eligibility; documentation does not guarantee coverage.

    • Include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures.
    • Maintain the supporting documentation in the patient's medical record and make it available upon request.

    Policy Background

    This policy addresses hereditary cancer genetic testing, including BRCA1 and BRCA2 testing for hereditary breast and ovarian cancer, as well as hereditary cancer panels. The scope includes panels related to hereditary breast, ovarian, endometrial, colon and Lynch syndrome, prostate, pan-cancer, and neuroendocrine tumor disorders.

    Non-Covered Conditions

    FDA approval alone is not a basis for coverage. FDA approval or clearance by itself does not establish coverage under this policy.

    Policy Summary
    PayerColorado Rocky Mountain Health Plans
    PolicyGenetic Testing for Hereditary Cancer (for North Carolina Only)
    Policy CodePolicy CSNCT0049.01
    Change TypeNew medical policy
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionEnsure the medical record contains legible documentation supporting medical necessity for the requested genetic testing, including relevant history, examination findings, and pertinent diagnostic results.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaApplicable CodesDocumentation RequirementsPolicy BackgroundNon-Covered Conditions