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    v1.0.28
    OpenPayerPolicy UpdatesGenetic & Molecular TestingCommunity Health Plan Washington Concert Genetics …
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    CurrentCommunity Health Plan WashingtonPolicy N/A

    Application of the Concert Genetics Clinical Policies for Medicare Beneficiaries

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    Governs how Concert Genetics molecular genetic test medical necessity criteria are applied for Medicare Advantage members of Centene-affiliated health plans when Medicare NCDs/LCDs do not fully establish coverage; affects providers ordering genetic tests for these members.

    Policy Summary
    PayerCommunity Health Plan Washington
    PolicyApplication of the Concert Genetics Clinical Policies for Medicare Beneficiaries
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionWhen Medicare NCDs/LCDs do not fully establish coverage, follow Concert Genetics medical necessity criteria and plan-specific prior authorization processes.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    biannualcriteria update frequency
    NCDs/LCDs + Concert Geneticscoverage sources applied
    publicpolicy availability

    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.

    Coverage Determination Rules

    Coverage decision hierarchy

    Coverage determination process for Medicare Advantage members affiliated with Centene:

    Hierarchy: 1) Apply Traditional Medicare national coverage determinations (NCDs) and local coverage determinations (LCDs) first; 2) If an applicable NCD or LCD fully establishes coverage for a molecular genetic test, follow the Medicare determination; 3) If an applicable NCD or LCD does not fully establish coverage for a molecular genetic test, apply the applicable medical necessity criteria from the Concert Genetics clinical policies for that test.

    Concert Genetics criteria are adopted from evidence‑based professional guidelines and updated biannually.

    For Medicare Advantage members, Traditional Medicare NCDs and LCDs take precedence for coverage determinations. When an applicable Medicare statute, regulation, NCD or LCD does not fully establish coverage for a molecular genetic test, Centene-affiliated plans will apply the Concert Genetics medical necessity criteria for that test and use those criteria to inform prior authorization and coverage decisions.

    This document does not provide a standalone list of items designated as Not Medically Necessary. Instead, when Medicare NCDs/LCDs do not fully address coverage for a molecular genetic test, providers and reviewers should consult and apply the Concert Genetics clinical policy criteria to determine medical necessity.

    Covered indications — hierarchy and source

    Covered indications are determined as follows:

    Primary source: When an applicable Medicare NCD or LCD does not fully establish coverage for a molecular genetic test, covered indications are those specified within the applicable Concert Genetics clinical policy for that test.

    Specific test‑by‑test indications, references, and evidence summaries are provided within each Concert Genetics policy and are publicly accessible on Centene‑affiliated plan websites and on the Concert Genetics website.

    Which Indications Are Covered

    Indications covered by Concert Genetics policies

    Indications covered are those specified within Concert Genetics clinical policies when Medicare NCDs/LCDs do not fully establish coverage.

    Covered indications: Apply the specific medical necessity criteria listed in the Concert Genetics clinical policy for the individual molecular genetic test when an applicable Medicare NCD or LCD does not fully establish coverage.

    Concert Genetics criteria are evidence‑based, adopted from professional society and standards‑body guidelines, and are updated biannually; see the individual policy for required documentation and any prior‑testing or ordering requirements.

    Member Eligibility

    No eligibility-specific top-level requirements are listed in this summary document. For member eligibility criteria applicable to a particular molecular genetic test, refer to the specific Concert Genetics clinical policy and any applicable Medicare NCD/LCD referenced therein.

    No additional eligibility-specific top-level requirements are specified here. Consult the individual Concert Genetics clinical policy for the test being ordered and applicable Medicare NCDs/LCDs to determine any test-specific eligibility conditions.

    Provider Responsibilities and Prior Authorization

    Prior Authorization

    Prior Authorization Required

    When Medicare NCDs/LCDs do not fully establish coverage for a molecular genetic test, prior authorization decisions must follow the Concert Genetics medical necessity criteria. Providers should submit requests using the plan-specific prior authorization process and include documentation that directly maps the patient case to the applicable Concert Genetics criteria.

    • Apply Concert Genetics clinical policy criteria when Medicare NCD/LCD are silent or incomplete
    • Use plan-specific prior authorization procedures aligned to Concert Genetics criteria
    Documentation Required

    Documentation of Medical Necessity

    Document medical necessity by citing the specific Concert Genetics clinical policy criteria and the supporting guideline references. Include relevant clinical details (diagnosis, prior testing, treatment implications) that demonstrate how the patient meets the numbered criteria in the Concert Genetics policy.

    Exclusions and Not Covered Items

    This document does not enumerate specific tests or indications that are categorically excluded. Exclusion or denial decisions follow the primacy of Medicare NCDs/LCDs where they fully establish coverage; when Medicare determinations are incomplete, exclusion decisions are guided by the applicable Concert Genetics medical necessity criteria.

    Key Definitions

    Concert Genetics clinical policies — definition and role as evidence-based medical necessity criteria
    DefinitionConcert Genetics clinical policies are evidence-based medical necessity criteria for molecular genetic tests, adopted from professional society and standards body guidelines.
    PurposeProvide test-specific medical necessity criteria to be applied when Medicare NCDs/LCDs do not fully establish coverage for a molecular genetic test.
    Evidence baseCriteria are adopted from evidence-based professional guidelines (e.g., ASCO, ACC) and standards bodies (e.g., NCCN).
    Update frequencyCriteria are updated biannually to reflect guideline changes and new publications.
    AvailabilityPolicies, references, and evidence summaries are publicly accessible on Centene-affiliated plan websites and the Concert Genetics website.
    Medicare NCDs/LCDs — definition and precedence for Medicare Advantage members

    Background and Purpose

    The Concert Genetics clinical policies provide evidence-based medical necessity criteria for molecular genetic tests, adopted from professional society guidelines and standards bodies. These criteria balance the benefits of testing against the harms of not testing, are updated biannually, and include references and evidence summaries; policies are publicly accessible on Centene-affiliated plan websites and the Concert Genetics website.

    Policy Summary
    PayerCommunity Health Plan Washington
    PolicyApplication of the Concert Genetics Clinical Policies for Medicare Beneficiaries
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionWhen Medicare NCDs/LCDs do not fully establish coverage, follow Concert Genetics medical necessity criteria and plan-specific prior authorization processes.
    SourceLink
    On This Page
    Coverage Determination RulesWhich Indications Are CoveredMember EligibilityProvider Responsibilities and Prior AuthorizationExclusions and Not Covered ItemsKey DefinitionsBackground and Purpose
    • Reference the exact Concert Genetics policy and guideline citations used to justify testing
    • Provide clinical rationale linking patient findings to criteria (e.g., indication, prior test results, impact on management)
    Denial Risk

    Denial Risk if Criteria Not Met

    Coverage may be denied if applicable Medicare NCD/LCD do not establish coverage and the submitted documentation does not meet the Concert Genetics medical necessity criteria. Providers should anticipate denials when requests lack explicit alignment to the Concert Genetics criteria or supporting guideline evidence.

    • Denial risk when Concert Genetics criteria are not met and Medicare NCD/LCD are silent
    • Ensure submitted records clearly demonstrate how each required criterion is satisfied to avoid denial
    Note

    Provider Actions

    Follow all plan-specific ordering and prior authorization procedures. Contact the plan's provider services or prior authorization contact point if there is uncertainty about which Concert Genetics policy applies or what documentation is required.

    • Follow plan-specific ordering and prior authorization procedures aligned to Concert Genetics criteria
    • Contact plan prior authorization support for questions about applicable Concert Genetics policy
    DefinitionMedicare NCDs/LCDs are Traditional Medicare national and local coverage determinations that establish coverage rules for Medicare beneficiaries.
    Precedence for MA membersFor all Medicare Advantage lines of business, Centene-affiliated health plans apply Medicare NCDs and LCDs first when determining coverage.
    Interaction with Concert GeneticsWhen an applicable Medicare statute, regulation, NCD or LCD does not fully establish coverage for a molecular genetic test, Centene will apply Concert Genetics medical necessity criteria.
    ScopeApplies specifically to molecular genetic test coverage determinations for Medicare Advantage members of Centene-affiliated plans.