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

Genetic Testing: Cardiovascular

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This policy governs coverage, medical-necessity review, and prior-authorization requirements for genetic, genomic, and molecular testing used to diagnose or manage inherited and sporadic cardiovascular conditions across Commercial, Wisconsin Medicaid/BadgerCare Plus, Medicare Advantage, Third Party Administration, and Family Health Center products.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyGenetic Testing: Cardiovascular

Policy CodePolicy N/A

Change TypeOperational updateno material clinical or coverage changes

Effective DateJanuary 1, 2026

Last ReviewDec 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for applicable genetic, genomic, and molecular testing before services are performed.

SourceLink

POLICY UPDATE CHANGES

Align, Align DSNP, and Great Plains Medicare Advantage plans were added to the policy.

Prior-authorization requirements were established for Medicare Advantage products and Align-related Medicare Advantage plans.

RequiredCommercial prior authorization

RequiredBadgerCare Plus/Medicaid SSI prior authorization

12Wisconsin Medicaid genetic test categories identified as covered per the ForwardHealth fee schedule

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

Genetic Testing: Cardiovascular

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Sign up for all security_health_plan_of_wisconsin_inc policy alerts

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Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyGenetic Testing: Cardiovascular

Policy CodePolicy N/A

Change TypeOperational updateno material clinical or coverage changes

Effective DateJanuary 1, 2026

Last ReviewDec 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for applicable genetic, genomic, and molecular testing before services are performed.

SourceLink

POLICY UPDATE CHANGES

Align, Align DSNP, and Great Plains Medicare Advantage plans were added to the policy.

Prior-authorization requirements were established for Medicare Advantage products and Align-related Medicare Advantage plans.

RequiredCommercial prior authorization

RequiredBadgerCare Plus/Medicaid SSI prior authorization

12Wisconsin Medicaid genetic test categories identified as covered per the ForwardHealth fee schedule

Not coveredFull genome and exome sequencing for Wisconsin Medicaid/BadgerCare Plus

No coverageFamily Health Center services obtained from out-of-network providers

Coverage Criteria

Commercial clinical authorization criteria

Commercial coverage is determined using Concert Genetics Navigator in InterQual format. Covered when the applicable criteria for the individual test are met.

Commercial medical necessity: The test must meet the applicable clinical authorization criteria for the individual test.

Testing that does not meet the applicable criteria is not medically necessary; testing performed for another reason is considered experimental.

Wisconsin Medicaid and BadgerCare Plus coverage

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.

Medicaid clinical usefulness

Testing is part of routine or targeted clinical screening.
Testing has a clinically useful impact on health outcomes.
Evidence-based guidelines, including those developed or endorsed by NCCN, ACMG, or ACOG, may inform the determination.

Wisconsin Medicaid covered test categories

For Wisconsin Medicaid and BadgerCare Plus, the following categories are identified as covered per the ForwardHealth fee schedule.

Covered cardiovascular test categories

Comprehensive cardiomyopathy panel.
Comprehensive arrhythmia and cardiomyopathy panel for sudden cardiac or unexplained death.
Dilated cardiomyopathy panel.
Arrhythmogenic cardiomyopathy panel.
Restrictive cardiomyopathy panel.
Long QT syndrome panel.

Tests requiring ForwardHealth fee-schedule review

For the following tests, review the ForwardHealth fee schedule to determine coverage.

Fee-schedule determination required

Comprehensive arrhythmia panel.
Hypertrophic cardiomyopathy panel.
Brugada syndrome panel or SCN5A variant analysis.

Full genome and exome sequencing are not covered for Wisconsin Medicaid and BadgerCare Plus members.

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 authorization criteria is considered not medically necessary. Testing performed for a reason other than those listed in the applicable criteria is considered experimental.

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

Coding Reference

Medicare molecular pathology procedure referenceHCPCS

L35000

Molecular Pathology Procedures

Authorization and Provider 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 determined using Concert Genetics Navigator in InterQual format.

Applies to Commercial products.
Submit the applicable prior authorization request before testing.

Prior Authorization

Wisconsin Medicaid Prior Authorization Required

Prior authorization is required for genetic, genomic, and molecular testing for BadgerCare Plus and Medicaid SSI members. The member must meet applicable clinical criteria when the claim is submitted, or payment may be impacted.

Use the ForwardHealth Physician Handbook and Maximum Allowable Fee Schedule to identify payable services, provider types, places of service, and services requiring prior authorization.
Submit prior authorization through the ForwardHealth process under: Online Handbook → BadgerCare Plus & Medicaid → Physician → Prior Authorization → Prior Authorization Guidelines → Genetic Testing.

Policy Background

This policy addresses genetic evaluation used to diagnose and manage inherited and sporadic cardiovascular conditions, including structural or electrical disorders, blood-vessel disorders, cholesterol disorders, and lipid profiling. Cardiovascular genetic testing may support diagnosis, treatment management, family evaluation, and risk assessment.

Key Definitions

Close relatives

DefinitionClose relatives are first-, 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.

Phenocopy

DefinitionA trait or disease that resembles the trait expressed by a certain genotype.

Genotype status

Covered Cardiovascular Testing Indications

Diagnosis and management of inherited and sporadic cardiovascular conditions

Genetic testing is intended to support diagnosis and management of inherited and sporadic cardiovascular conditions.

Covered cardiovascular indications

Structural cardiovascular defects.
Electrical cardiovascular defects.
Disorders of the blood vessels.
Cholesterol disorders.
Lipid profiling.

Eligibility Requirements

For cardiovascular genetic assessment, close relatives include first-, second-, and third-degree 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. Specific family-history criteria are determined through the applicable clinical authorization criteria.

The policy does not require universal prior genetic testing before a new test is considered. Eligibility for individual tests is determined under the applicable product criteria, including the applicable clinical authorization criteria or Concert Genetics Navigator in InterQual format.

Excluded Services and Tests

For Wisconsin Medicaid and BadgerCare Plus, full genome and exome sequencing are not covered. Genetic testing is also not covered when the results would not have a clinically useful impact on health outcomes. Coverage remains subject to applicable clinical criteria and ForwardHealth requirements.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyGenetic Testing: Cardiovascular

Policy CodePolicy N/A

Change TypeOperational updateno material clinical or coverage changes

Effective DateJanuary 1, 2026

Last ReviewDec 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for applicable genetic, genomic, and molecular testing before services are performed.

SourceLink

On This Page

Short QT syndrome panel.

Catecholaminergic polymorphic ventricular tachycardia panel.

Familial hypercholesterolemia panel.

Congenital heart malformation panel.

Familial thoracic aortic aneurysm and dissection multigene panel.

Hereditary hemorrhagic telangiectasia multigene panel.

Prior Authorization

Medicare Advantage Prior Authorization

Medicare Advantage prior authorization requirements are product- and date-specific. The Health Plan follows Medicare guidelines and applies the Commercial policy when Medicare has not issued a national or Wisconsin local coverage determination for the procedure.

Medicare Advantage: prior authorization is not required before 3/1/2026; prior authorization is required effective 3/1/2026.
Align, Align DSNP, and Great Plains: prior authorization through the Health Plan is required beginning 1/1/2026.
For Molecular Pathology Procedures (L35000), follow the applicable Health Plan determination and Medicare Advantage requirements.

Prior Authorization

TPA Prior Authorization Required

Prior authorization is required for genetic, genomic, and molecular testing for Third Party Administration (TPA) groups that use the Health Plan to process services. Submit the Genetic, Genomic and Molecular Testing Prior Authorization Request.

If the group’s Summary Plan Description does not contain specific guidelines or criteria, apply the Commercial criteria.

Unsupported block type: documentation

Unsupported block type: denial_risk

Unsupported block type: documentation

The individual does not carry that genotype.

Clinical distinctionThe genotype-associated trait is present without the associated genotype being carried.

Premature coronary artery disease

DefinitionPremature coronary artery disease (CAD).

Male thresholdMale subjects at or under 55 years of age.

Female thresholdFemale subjects at or under 65 years of age.

Sudden cardiac death

DefinitionSudden cardiac death (SCD).

CauseDeath due to a cardiovascular cause.

TimingOccurs within one hour of the onset of symptoms.

Sudden unexplained death

DefinitionSudden unexplained death (SUD), also known as sudden unexplained death syndrome or SUDS.

IndividualSudden cardiac death in an apparently healthy and often young individual.

Timing and reasonOccurs within one hour of symptom onset and for no apparent reason.

Type A aortic dissection

DefinitionType A aortic dissection.

Aortic locationOccurs at the ascending part of the aorta.

Anatomic descriptionThe ascending aorta is just as it branches off of the heart.

Type B aortic dissection

DefinitionType B aortic dissection.

Aortic locationOccurs at the descending part of the aorta.

Possible extensionMay extend into the abdomen.

Specified cardiovascular genetic test categories

The following cardiovascular genetic test categories are listed as covered per the ForwardHealth fee schedule.

Specified covered cardiovascular test categories

Comprehensive cardiomyopathy panels.
Comprehensive arrhythmia and cardiomyopathy panels for sudden cardiac or unexplained death.
Dilated cardiomyopathy panels.
Arrhythmogenic cardiomyopathy panels.
Restrictive cardiomyopathy panels.
Long QT syndrome panels.
Short QT syndrome panels.
Catecholaminergic polymorphic ventricular tachycardia panels.
Familial hypercholesterolemia panels.
Congenital heart malformation panels.
Familial thoracic aortic aneurysm and dissection multigene panels.
Hereditary hemorrhagic telangiectasia multigene panels.