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    v1.0.28
    OpenPayerPolicy UpdatesGenetic & Molecular TestingSecurity Health Hereditary Cancer Coverage | OpenP…
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    ModifiedSecurity Health Plan of Wisconsin, Inc.Policy N/A

    Genetic Testing Oncology: Hereditary Cancer

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    Coverage, medical-necessity review, and prior-authorization requirements for genetic testing used to evaluate hereditary cancer susceptibility across Commercial, Medicaid/BadgerCare Plus, Family Health Center, Medicare Advantage, and third-party administration products.

    Policy Summary
    PayerSecurity Health Plan of Wisconsin, Inc.
    PolicyGenetic Testing Oncology: Hereditary Cancer
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateJanuary 1, 2026
    Last ReviewDec 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization through the Health Plan for applicable hereditary cancer genetic testing before services are performed.
    SourceLink
    POLICY UPDATE CHANGES

    Prior-authorization requirements were established or clarified for multiple product segments, including Medicare Advantage and Align products.

    CDKN2A sequencing and deletion/duplication analysis was changed to covered for specified clinical indications.

    Hereditary cancer testing criteria and covered test lists were expanded and reorganized across multiple genes, panels, and cancer syndromes to align with clinical guidelines.

    Prior authorization is required through the Health Plan for Align, Align DSNP, and Great Plains beginning January 1, 2026.

    CDKN2A sequencing and/or deletion/duplication analysis was changed to covered for specified clinical indications.

    BRCA1, BRCA2, and PALB2 testing criteria were expanded or clarified to allow coverage for additional clinical indications, including ampullary adenocarcinoma.

    PALB2 testing criteria and the PALB2 gene were removed from the minimum gene list for hereditary breast cancer susceptibility panels.

    The hereditary breast cancer susceptibility panel criterion requiring the member to be at least 18 years old was removed.

    Hereditary prostate cancer, hereditary neuroendocrine cancer, and other gene-specific testing criteria were clarified or simplified to better align with updated professional guidelines.

    Primary C-cell hyperplasia was removed as an indication for RET sequencing and/or deletion/duplication analysis.

    Family history of pediatric hypodiploid acute lymphoblastic leukemia was added as a TP53 testing criterion.

    The SMAD4 and/or BMPR1A criterion for a pathogenic or likely pathogenic mutation detected on tumor profiling was removed.

    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.

    PA requiredCommercial hereditary cancer testing
    CDKN2ACDKN2A indications changed to covered
    2Excluded Medicaid/BadgerCare hereditary panel categories
    Not coveredMedicaid/BadgerCare genome and exome sequencing
    MultipleProduct-specific coverage pathways
    Ampullary cancerAdditional BRCA1/2/PALB2 indication

    Coverage Criteria

    For Wisconsin Medicaid and BadgerCare Plus, full genome and exome sequencing are not covered.

    Pan-Cancer Hereditary Cancer Susceptibility Panels are not covered under the ForwardHealth fee schedule.

    Hereditary Gastrointestinal/Colorectal Cancer Susceptibility Panels are not covered under the ForwardHealth fee schedule.

    For Family Health Center members, BRCA1 and BRCA2 testing follows the applicable Commercial criteria. All other genetic tests addressed by this policy are not covered under the Family Health Center Member Handbook.

    For Commercial members, testing that does not meet the applicable authorization and clinical criteria is considered not medically necessary. Testing performed for reasons other than those listed in the criteria is considered experimental.

    Wisconsin Medicaid and BadgerCare Plus cover genetic testing when it is part of routine or targeted clinical screening and has a clinically useful impact on health outcomes. Testing is not covered when the results would not have that impact.

    Covered Indications and Test Categories

    Hereditary Cancer Susceptibility Panels

    Under the BadgerCare Plus/Medicaid SSI pathway, the following panel categories are covered per the ForwardHealth fee schedule, subject to applicable clinical criteria and prior authorization.

    ONE of the following covered panel categories

    • Hereditary gastric cancer susceptibility panel
    • Hereditary polyposis susceptibility panel
    • Hereditary neuroendocrine cancer susceptibility panel

    CDKN2A Testing

    CDKN2A testing is covered for specified clinical indications when the applicable clinical criteria and prior-authorization requirements are met.

    ONE of the following testing methods

    • CDKN2A sequencing analysis
    • CDKN2A deletion/duplication analysis

    BRCA1, BRCA2, and PALB2 Testing

    Testing is covered for the following additional clinical indication when the applicable clinical criteria and prior-authorization requirements are met.

    The member has ampullary adenocarcinoma.

    TP53 Testing

    TP53 testing is covered when the applicable clinical criteria and prior-authorization requirements are met.

    The member has a family history of pediatric hypodiploid acute lymphoblastic leukemia.

    Eligibility Requirements

    Hereditary cancer eligibility may rely on family history involving close blood relatives. First-degree relatives are parents, siblings, and children; second-degree relatives include grandparents, aunts, uncles, nieces, nephews, grandchildren, and half siblings; and third-degree relatives include great-grandparents, great-aunts, great-uncles, great-grandchildren, and first cousins. The policy also identifies specific hereditary cancer provisions, including family history of pediatric hypodiploid acute lymphoblastic leukemia for TP53 testing and clarified family-history criteria for selected genes and cancer syndromes.

    The policy does not state specific general prior-testing requirements. Known familial variant testing is within the scope of the related General Approach to Laboratory Testing policy when it is not specifically addressed here. Eligibility may also depend on the applicable gene- or syndrome-specific clinical criteria and documented family history.

    Coding and Clinical Thresholds

    Medicare molecular and genomic procedure referencesHCPCS
    L35000Molecular Pathology Procedures
    L37810Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms
    L37606Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases
    A56793Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases
    A55974Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases
    Removed historical codeCPT
    0104UCPT code noted as removed in a prior policy update
    High-risk prostate cancer PSA
    ConditionHigh-risk prostate cancer
    PSA threshold> 20 ng/mL
    QualificationAn individual with one or more high-risk features who does not meet criteria for very-high-risk prostate cancer
    Very-high-risk prostate cancer PSA
    ConditionVery-high-risk prostate cancer
    PSA threshold> 40 ng/mL
    Additional definition

    Authorization and Provider Actions

    Prior Authorization

    Commercial Prior Authorization Required

    Prior authorization is required for Commercial hereditary cancer genetic testing. The Health Plan uses Concert Genetics Navigator in InterQual format to determine medical necessity.

    • Submit the Genetic, Genomic and Molecular Testing Prior Authorization Request.
    Prior Authorization

    BadgerCare Plus and Medicaid SSI Authorization

    Prior authorization is required for BadgerCare Plus and Medicaid SSI genetic testing. Services must meet applicable ForwardHealth clinical and authorization requirements when the claim is submitted.

    • Use the ForwardHealth fee schedule to identify payable services and services requiring prior authorization.
    • Review the ForwardHealth Physician Handbook for genetic testing coverage, prior authorization, genetic counseling, documentation, and noncovered-service requirements.

    Policy Background

    This policy addresses germline genetic testing used to evaluate inherited susceptibility to hereditary cancers. It distinguishes hereditary susceptibility testing from tumor biomarker and somatic molecular profiling, cancer screening, and other molecular diagnostic services addressed by related policies. Coverage depends on clinical usefulness, product-specific criteria, and applicable prior-authorization requirements.

    Definitions

    Close relatives
    DefinitionFirst-, second-, and third-degree blood relatives
    First-degree relativesParents, siblings, and children
    Second-degree relativesGrandparents, aunts, uncles, nieces, nephews, grandchildren, and half siblings
    Third-degree relativesGreat grandparents, great aunts, great uncles, great grandchildren, and first cousins
    Adenomatous polyposis
    DefinitionConditions that cause multiple adenomas in the gastrointestinal tract
    Adenomas

    Not Covered Services

    The following services are not covered under the applicable product rules: full genome and exome sequencing for Wisconsin Medicaid and BadgerCare Plus; Pan-Cancer Hereditary Cancer Susceptibility Panels; Hereditary Gastrointestinal/Colorectal Cancer Susceptibility Panels under the ForwardHealth fee schedule; and, for Family Health Center members, all genetic tests addressed by this policy other than BRCA1 and BRCA2 testing.

    Policy Summary
    PayerSecurity Health Plan of Wisconsin, Inc.
    PolicyGenetic Testing Oncology: Hereditary Cancer
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateJanuary 1, 2026
    Last ReviewDec 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization through the Health Plan for applicable hereditary cancer genetic testing before services are performed.
    SourceLink
    On This Page
    Coverage CriteriaCovered Indications and Test CategoriesEligibility RequirementsCoding and Clinical ThresholdsAuthorization and Provider ActionsPolicy BackgroundDefinitionsNot Covered Services
    An individual with at least two specified very-high-risk features
    High-risk breast cancer invasive primary tumor
    Cancer settingHigh-risk breast cancer for olaparib therapy
    Invasive primary tumorGreater than or equal to 2 cm on pathology analysis
    Treatment contextTriple-negative breast cancer treated with adjuvant chemotherapy
    High-risk breast cancer lymph nodes
    Cancer settingHigh-risk breast cancer for olaparib therapy
    Positive lymph nodesFour or more positive pathologically confirmed lymph nodes
    Treatment contextHormone receptor-positive disease treated with adjuvant chemotherapy
    High-risk breast cancer CPS+CG score
    Cancer settingHigh-risk breast cancer for olaparib therapy
    CPS+CG score3 or higher
    Treatment contextNeoadjuvant chemotherapy without a complete pathologic response in hormone receptor-positive disease
    Prior Authorization

    Family Health Center Authorization

    Prior authorization is required for Family Health Center members. BRCA1 and BRCA2 testing follows the Commercial criteria; all other genetic tests addressed by this policy are not covered under the Family Health Center Member Handbook.

    • Submit the Genetic, Genomic and Molecular Testing Prior Authorization Request for BRCA1/BRCA2 testing.

    Unsupported block type: prior_auth

    Prior Authorization

    Align Product Authorization

    Prior authorization is required through the Health Plan for applicable Align, Align DSNP, and Great Plains molecular pathology and genomic services.

    • Applicable services include molecular pathology procedures and genomic sequence analysis panels identified in the policy.
    • The Health Plan follows Medicare guidelines for these products.
    Prior Authorization

    TPA Prior Authorization

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

    • Submit the Genetic, Genomic and Molecular Testing Prior Authorization Request.
    • Review the member's Summary Plan Description to determine coverage, limitations, exclusions, and whether Commercial criteria apply.
    Prior Authorization

    Required Authorization Beginning January 1, 2026

    Beginning January 1, 2026, prior authorization is required through the Health Plan for Align, Align DSNP, and Great Plains services subject to the policy.

    • Verify the product and obtain authorization before performing applicable molecular pathology or genomic services.
    Documentation Required

    Verify Member Benefit Documents

    Before determining benefits, review the member's Schedule of Benefits and Certificate.

    • Confirm the member-specific benefit documents before advising the member or proceeding with testing.
    Documentation Required

    Consult ForwardHealth Requirements

    Use ForwardHealth resources to confirm coverage and authorization requirements for BadgerCare Plus and Medicaid SSI genetic testing.

    • Review the ForwardHealth Physician Handbook, including Genetic Testing prior authorization guidelines.
    • Check the ForwardHealth fee schedule for payable services, provider requirements, places of service, and services requiring prior authorization.
    • Review ForwardHealth noncovered genetic testing requirements.
    Documentation Required

    Review TPA Plan Documents

    For TPA groups using the Health Plan, review the member's Summary Plan Description to determine whether the services are covered and whether Commercial criteria apply.

    • Check the SPD for specific coverage guidelines, limitations, and exclusions.
    Denial Risk

    Does Not Meet Clinical Criteria

    Commercial testing that does not meet the applicable clinical criteria is not medically necessary. Testing performed for reasons other than those listed in the criteria is considered experimental.

    • Confirm that the requested test and indication satisfy the applicable Commercial clinical criteria before ordering.
    Denial Risk

    No Clinically Useful Impact or Genome/Exome Sequencing

    BadgerCare Plus and Medicaid SSI do not cover genetic testing when the results would not have a clinically useful impact on health outcomes, and they do not cover full genome or exome sequencing.

    • Confirm that testing is part of routine or targeted clinical screening with a clinically useful impact on health outcomes.
    • Do not submit full genome or exome sequencing for coverage under these programs.
    Denial Risk

    Excluded Hereditary Panels

    The following hereditary panels are not covered under the ForwardHealth fee schedule.

    • Pan-cancer hereditary cancer susceptibility panels.
    • Hereditary gastrointestinal/colorectal cancer susceptibility panels.
    Denial Risk

    Family Health Center Noncoverage

    For Family Health Center members, genetic tests other than BRCA1 and BRCA2 testing are not covered under the Family Health Center Member Handbook.

    • BRCA1 and BRCA2 testing remains subject to prior authorization and Commercial criteria.
    Prior Authorization

    Required Prior Authorization

    Beginning January 1, 2026, Align, Align DSNP, and Great Plains require prior authorization through the Health Plan for applicable services.

    • Obtain authorization before performing applicable molecular pathology and genomic services.
    Documentation Required

    Genetic Counseling

    Pre-test and post-test genetic counseling are strongly advised to support informed testing decisions and interpretation of results.

    Documentation Required

    Submit the Prior Authorization Request

    The ordering provider should submit the applicable Genetic, Genomic and Molecular Testing Prior Authorization Request when prior authorization is required.

    • Include the clinical information and documentation required by the applicable product and program.
    Benign polyps
    Anatomic siteGastrointestinal tract
    Breast cancer
    DefinitionA term that applies to patients with invasive cancer or ductal carcinoma in situ
    Invasive diseaseInvasive breast cancer
    In situ diseaseDuctal carcinoma in situ (DCIS)
    Lynch syndrome-related cancer
    DefinitionCancer types associated with Lynch syndrome
    Common examplesColorectal, endometrial, gastric, ovarian, and pancreatic cancers
    Additional examplesUreter and renal pelvic, brain, biliary tract, and small intestinal cancers
    Other associated tumorsSebaceous adenoma, sebaceous carcinoma, and keratoacanthoma
    High-risk and very-high-risk prostate cancer
    High-risk clinical stagecT3-cT4a
    High-risk grade groupGrade Group 4 or 5
    High-risk PSAPSA > 20 ng/mL
    Very-high-risk clinical stagecT3-cT4
    Very-high-risk PSAPSA > 40 ng/mL
    Very-high-risk definitionAt least two of the specified very-high-risk features