CurrentSecurity Health Plan of Wisconsin, Inc.Policy N/A

Genetic Testing: Nutrition and Metabolism

Customize your policy alerts

Sign up for all security_health_plan_of_wisconsin_inc policy alerts

Know when security_health_plan_of_wisconsin_inc releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs coverage and utilization management for genetic, genomic, and molecular testing related to nutrition, metabolic, endocrine, and mitochondrial conditions across specified Health Plan products. Coverage, prior authorization, and medical-necessity requirements vary by product, including Commercial, Medicaid, Medicare Advantage, Family Health Center, and Third Party Administration plans.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyGenetic Testing: Nutrition and Metabolism

Policy CodePolicy N/A

Change TypeMaterial policy update

Effective DateJanuary 1, 2026

Last ReviewDec 1, 2025

Next Review DateN/A

Key ActionSubmit the Genetic, Genomic and Molecular Testing Prior Authorization Request when prior authorization is required.

SourceLink

POLICY UPDATE CHANGES

The policy added Align, Align DSNP, and Great Plains Medicare Advantage plans with prior authorization required beginning January 1, 2026.

Prior authorization will be required for Medicare Advantage plans beginning March 1, 2026.

Medicaid information was updated in December 2025, including ForwardHealth coverage and authorization pathways.

The policy transitioned to Concert Genetics Navigator in InterQual format for medical-necessity determinations.

Known familial variant testing criteria were moved to the General Approach to Genetic and Molecular Testing policy.

1/1/2026Current effective date

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.

CurrentSecurity Health Plan of Wisconsin, Inc.Policy N/A

Genetic Testing: Nutrition and Metabolism

Customize your policy alerts

Sign up for all security_health_plan_of_wisconsin_inc policy alerts

Know when security_health_plan_of_wisconsin_inc releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyGenetic Testing: Nutrition and Metabolism

Policy CodePolicy N/A

Change TypeMaterial policy update

Effective DateJanuary 1, 2026

Last ReviewDec 1, 2025

Next Review DateN/A

Key ActionSubmit the Genetic, Genomic and Molecular Testing Prior Authorization Request when prior authorization is required.

SourceLink

POLICY UPDATE CHANGES

The policy added Align, Align DSNP, and Great Plains Medicare Advantage plans with prior authorization required beginning January 1, 2026.

Prior authorization will be required for Medicare Advantage plans beginning March 1, 2026.

Medicaid information was updated in December 2025, including ForwardHealth coverage and authorization pathways.

The policy transitioned to Concert Genetics Navigator in InterQual format for medical-necessity determinations.

Known familial variant testing criteria were moved to the General Approach to Genetic and Molecular Testing policy.

1/1/2026Current effective date

3/1/2026Medicare Advantage prior authorization start date

6Medicaid/BadgerCare covered test categories

1Medicaid/BadgerCare test category not covered

12/1/2025Last review date

Product-Specific Coverage Criteria

Commercial clinical authorization criteria

Covered when the applicable medical-necessity criteria are met:

Commercial medical necessity

The requested genetic, genomic, or molecular test must meet the applicable Concert Genetics Navigator criteria in InterQual format.
The individual test criteria are not reproduced in this policy.

BadgerCare Plus and Medicaid SSI coverage

Covered for Wisconsin Medicaid and BadgerCare Plus when all of the following are met:

Medicaid clinical usefulness and payment

The testing is part of routine or targeted clinical screening.
The testing has been determined to have a clinically useful impact on health outcomes.
Evidence-based guidelines, including applicable guidelines from NCCN, ACMG, or ACOG, may be used when published.
The service is covered and payable under the ForwardHealth fee schedule and applicable criteria.
Verify payable services, provider types, specialties, places of service, prior authorization, documentation, and other requirements in ForwardHealth resources.

Medicare Advantage coverage hierarchy

Apply the following coverage hierarchy:

Medicare policy hierarchy

Apply a Medicare local coverage determination (LCD) or national coverage determination (NCD) when available.
If no Medicare LCD or NCD is available, apply the Commercial policy criteria.

Third Party Administration coverage

Determine coverage in the following order:

TPA coverage hierarchy

Apply the group's Summary Plan Description (SPD) when it contains specific coverage guidelines or criteria.
If the SPD does not contain specific guidelines or criteria, apply the Commercial policy criteria.

For Commercial members, testing performed for a reason other than those listed in the applicable clinical criteria is considered experimental and is excluded.

Full genome and exome sequencing are excluded for Wisconsin Medicaid and BadgerCare Plus members.

MTHFR variant analysis is not covered under the ForwardHealth fee schedule.

The Family Health Center provides no coverage for services performed by out-of-network providers.

For Commercial members, testing that does not meet the applicable clinical criteria is considered not medically necessary or experimental and is not covered.

Wisconsin Medicaid and BadgerCare Plus do not cover genetic testing when the results would not have a clinically useful impact on health outcomes.

Medicare Molecular Pathology Procedures

Medicare Molecular Pathology ProceduresHCPCS

L35000

Molecular Pathology Procedures

Authorization and Documentation Requirements

Prior Authorization

Commercial Prior Authorization Required

Prior authorization is required for commercial genetic, genomic, and molecular testing. Submit the Genetic, Genomic and Molecular Testing Prior Authorization Request; medical necessity is evaluated using Concert Genetics Navigator in InterQual format.

Applies to Commercial members.
Testing that does not meet the clinical criteria is considered not medically necessary or experimental.
Testing performed for reasons other than those listed in the commercial criteria is considered experimental.

Prior Authorization

Medicaid Prior Authorization Required

Prior authorization is required for genetic testing for BadgerCare Plus and Medicaid SSI members. Submit the Genetic, Genomic and Molecular Testing Prior Authorization Request and ensure the member meets applicable clinical criteria when the claim is submitted.

The Health Plan will not be more restrictive than fee-for-service Medicaid under the BadgerCare Plus HMO contract.

Clinical Definitions

High myopia

DefinitionNear-sightedness of -6.00 diopters or greater or an axial length greater than 26.5 mm.

Marfanoid features or marfanoid habitus

DefinitionFeatures typically associated with Marfan syndrome, including but not limited to a disproportionately tall, slender build; abnormally long or slender fingers and toes; a protruding or caving sternum; and scoliosis.

Undernutrition

DefinitionA type of malnutrition defined by four categories: wasting, stunting, underweight, and micronutrient-related malnutrition.

WastingLow weight-for-height.

Covered Testing Categories and Clinical Use

Nutrition and metabolism testing covered under the ForwardHealth fee schedule

The following testing categories are covered under the ForwardHealth fee schedule:

Covered nutrition and metabolism testing

Serum 25-hydroxyvitamin D [25(OH)D] testing.
Serum 1,25-dihydroxyvitamin D [1,25(OH)2D] testing.
Serum vitamin B12 and/or folate testing.
Serum iron testing, including ferritin, iron, iron-binding capacity, and/or transferrin testing.
Serum/plasma homocysteine testing.

Explicit Non-Coverage Rules

For applicable Wisconsin Medicaid and BadgerCare Plus products, MTHFR variant analysis is not covered under the ForwardHealth fee schedule, and full genome and exome sequencing are not covered.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyGenetic Testing: Nutrition and Metabolism

Policy CodePolicy N/A

Change TypeMaterial policy update

Effective DateJanuary 1, 2026

Last ReviewDec 1, 2025

Next Review DateN/A

Key ActionSubmit the Genetic, Genomic and Molecular Testing Prior Authorization Request when prior authorization is required.

SourceLink

On This Page

A code covered under the ForwardHealth fee schedule is considered a covered procedure, subject to applicable clinical criteria and authorization requirements.

Unsupported block type: prior_auth，每?

Prior Authorization

TPA Prior Authorization Required

Prior authorization is required for genetic, genomic, and molecular testing for third-party administration groups that use the Health Plan to process services.

Review the member's Summary Plan Description (SPD) to determine coverage, limitations, and exclusions.
If the SPD does not specify guidelines or criteria, TPA groups using the Health Plan follow the commercial criteria.

Documentation Required

Submit Authorization and Verify Benefits

Before providing or billing testing, submit the applicable prior authorization request and verify the member's benefits and plan-specific coverage rules.

Use the Genetic, Genomic and Molecular Testing Prior Authorization Request when prior authorization is required.
Confirm benefits, limitations, and exclusions for the member's plan.
For TPA members, use the Summary Plan Description to confirm coverage.

Documentation Required

Use ForwardHealth Documentation and Fee Schedule

Use ForwardHealth resources to confirm coverage, clinical usefulness, documentation, genetic counseling, and prior authorization requirements for BadgerCare Plus and Medicaid SSI testing.

Review the ForwardHealth Physician Handbook for coverage, clinically useful criteria, prior authorization, genetic counseling, documentation requirements, and test-specific guidelines.
Use the ForwardHealth interactive fee schedule to verify payable services, provider types, specialties, places of service, and services requiring prior authorization.
Navigate to Physician → Covered and Noncovered Services → Covered Services and Requirements → Emerging Molecular Pathology and Diagnostic Genetic Testing.
For prior authorization guidance, navigate to Physician → Prior Authorization → Prior Authorization Guidelines → Genetic Testing.
For noncovered services, navigate to Physician → Covered and Noncovered Services → Noncovered Services → Noncovered Genetic Testing.

Denial Risk

Testing That Does Not Meet Clinical Criteria

Commercial testing that does not meet the applicable clinical criteria is not medically necessary or experimental. Testing performed for any reason other than those identified in the commercial criteria is considered experimental.

Review the commercial clinical authorization criteria before requesting or performing testing.
Failure to meet criteria may result in denial or treatment of the testing as experimental.

Denial Risk

No Clinically Useful Impact

Wisconsin Medicaid and BadgerCare Plus do not cover genetic testing when the results would not have a clinically useful impact on health outcomes.

Testing must be part of routine or targeted clinical screening with a clinically useful impact on health outcomes.
Clinical determinations may use evidence-based guidelines endorsed by entities such as NCCN, ACMG, and ACOG.

Denial Risk

Full Genome and Exome Sequencing Not Covered

Wisconsin Medicaid and BadgerCare Plus do not cover full genome sequencing or exome sequencing.

Do not submit full genome or exome sequencing as a covered Medicaid or BadgerCare Plus service.

Denial Risk

MTHFR Variant Analysis Not Covered

MTHFR variant analysis is listed as not covered under the ForwardHealth fee schedule.

Verify the current ForwardHealth fee schedule and noncovered genetic testing guidance before ordering or billing.

Denial Risk

Family Health Center Out-of-Network Services

Family Health Center (FHC) provides no coverage for services furnished by an out-of-network provider. FHC services are available only through out-of-network providers, so the applicable genetic testing service is not covered.

Confirm the member's FHC network and coverage before directing testing to an out-of-network provider.
Do not assume out-of-network genetic testing is covered under the FHC benefit.

Documentation Required

Provider Actions for Genetic Counseling

For Wisconsin Medicaid and BadgerCare Plus members, providers must follow the ForwardHealth Physician Handbook requirements for genetic counseling and document the applicable counseling and testing information with the authorization or claim.

Review the Physician Handbook's genetic counseling requirements before ordering genetic testing.
Confirm whether genetic counseling is required for the specific test and retain the required documentation.
Use the Physician Handbook and ForwardHealth resources for test-specific documentation and authorization instructions.

StuntingLow height-for-age.

UnderweightLow weight-for-age.

Micronutrient-related malnutritionMicronutrient deficiencies, meaning a lack of important vitamins and minerals, or micronutrient excess, such as obesity.

Testing for other covered metabolic disorders.

Routine or targeted clinical screening with clinically useful impact on health outcomes

For Wisconsin Medicaid and BadgerCare Plus, coverage requires all of the following:

Routine or targeted clinical screening with clinically useful impact

The testing is part of routine or targeted clinical screening.
The testing has been determined to have a clinically useful impact on health outcomes.
The service is payable under ForwardHealth requirements.