Concert Genetic Testing: Toxicology and Pharmacogenetics (Version B)
Defines medical necessity criteria, example tests, and coding implications for pharmacogenetic and toxicology-related genetic tests used to assess drug response, toxicity, and metabolizer status for members of Community Health Plan Washington (Centene-affiliated plans). Affects providers ordering or billing for pharmacogenetic and selected single-gene variant tests.
Multiple definitions and criteria were updated across gene variant analyses and the policy reference table; language changed and additional genes/tests and CPT codes were added.
FDA Table of Pharmacogenetic Associations recommendations were incorporated for multiple genes including HLA-B*15:02, HLA-B*57:01, TPMT/NUDT15, UGT1A1, UGT2B17, VKORC1, and NAT2.
Multiple single-gene and panel pharmacogenetic criteria and definitions were updated (examples: UGT1A1, UGT2B17, VKORC1, DPYD, HLA variants, NAT2, TPMT, NUDT15, CYP family genes) and CPT codes 0423U, 0434U, 0437U, 0438U were added to the coding reference table.
Pharmacogenetic panel testing criteria changed to require demonstrated clinical validity and added medically necessary panels and LCD-aligned indications (e.g., MDD, GAD) with age thresholds.
Warfarin Sensitivity Analysis Panels: clinical criteria were added to allow coverage of small targeted panels for this indication.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.