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

Genetic Testing: Respiratory

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This policy governs coverage, medical-necessity review, and prior-authorization requirements for diagnostic genetic and molecular tests for lung and other respiratory disorders across specified Health Plan product lines in Wisconsin.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyGenetic Testing: Respiratory

Policy CodePolicy N/A

Change TypeMaterial revision

Effective DateJanuary 1, 2026

Last ReviewDec 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization for applicable respiratory genetic testing before services are performed.

SourceLink

POLICY UPDATE CHANGES

Align, Align DSNP, and Great Plains Medicare Advantage plans were added to the policy with prior authorization required through the Health Plan beginning January 1, 2026.

Prior authorization for Medicare Advantage respiratory genetic testing is scheduled to become required effective March 1, 2026.

SERPINA1 testing criteria were updated in July 2024 to align with current guidelines and expand coverage.

The policy transitioned to Concert Genetics Navigator in InterQual format in January 2025 and removed the standalone reference table, definitions, background and rationale, and references.

3Covered respiratory testing categories

PA requiredCommercial, Medicaid, and TPA authorization

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

Genetic Testing: Respiratory

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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: Respiratory

Policy CodePolicy N/A

Change TypeMaterial revision

Effective DateJanuary 1, 2026

Last ReviewDec 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization for applicable respiratory genetic testing before services are performed.

SourceLink

POLICY UPDATE CHANGES

Align, Align DSNP, and Great Plains Medicare Advantage plans were added to the policy with prior authorization required through the Health Plan beginning January 1, 2026.

Prior authorization for Medicare Advantage respiratory genetic testing is scheduled to become required effective March 1, 2026.

SERPINA1 testing criteria were updated in July 2024 to align with current guidelines and expand coverage.

The policy transitioned to Concert Genetics Navigator in InterQual format in January 2025 and removed the standalone reference table, definitions, background and rationale, and references.

3Covered respiratory testing categories

PA requiredCommercial, Medicaid, and TPA authorization

3/1/2026Medicare Advantage authorization date

No coverageFamily Health Center out-of-network services

Not coveredMedicaid and BadgerCare Plus full genome and exome sequencing

Coverage Criteria

Commercial medical necessity

Commercial testing is covered when the applicable individual-test medical-necessity criteria are met.

Commercial respiratory genetic testing: The test must satisfy the applicable individual-test medical-necessity criteria in Concert Genetics Navigator in InterQual format.

Testing that does not meet the applicable criteria is not medically necessary. Testing performed for reasons other than the listed indications is considered experimental.

BadgerCare Plus and Medicaid SSI coverage

Wisconsin Medicaid and BadgerCare Plus cover genetic testing when all applicable clinical-usefulness and program requirements are met.

Clinical usefulness

Testing must be part of routine or targeted clinical screening and must have a clinically useful impact on health outcomes.
Evidence-based guidelines, including guidelines developed or endorsed by NCCN, ACMG, or ACOG, may be used to make this determination.

Program payment requirements

The service must be payable under the ForwardHealth fee schedule.
The member must meet the applicable clinical criteria when the claim is submitted.
Payment could be impacted if clinical criteria are not met at claim submission.

ForwardHealth covered test categories

The following respiratory genetic testing categories are identified as covered under the ForwardHealth fee schedule.

Covered respiratory test categories

Diagnostic CFTR sequencing and/or deletion/duplication analysis.
CFTR intron 9 PolyT and TG analysis, previously called intron 8 PolyT/TG analysis.
Other covered lung-disorder genetic testing.

SERPINA1 coverage

SERPINA1 testing requires review of the applicable ForwardHealth fee schedule.

SERPINA1 testing: SERPINA1 common variant analysis or sequencing and/or deletion/duplication analysis may be covered when the applicable ForwardHealth fee schedule identifies the service as covered.

Review the fee schedule before determining coverage; detailed clinical criteria are not reproduced in this policy.

Medicare Advantage coverage basis

Medicare Advantage coverage follows Medicare guidance when applicable.

Medicare policy hierarchy

Apply a Medicare LCD or NCD when one is available for the applicable molecular pathology procedure.
The policy references Molecular Pathology Procedures (L35000).
If no Medicare policy is available, apply the Commercial respiratory policy criteria to Medicare Advantage members.

TPA coverage

TPA coverage is determined under the member's plan documents.

TPA coverage requirements

The service must be covered under the member's Summary Plan Description (SPD).
Review the SPD for applicable limitations and exclusions.
If the SPD does not contain specific guidelines or criteria, Commercial criteria apply for TPA groups that use the Health Plan to process services.

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

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

For Commercial members, genetic testing performed for reasons other than the listed indications is considered experimental.

For Commercial members, testing that does not meet the applicable individual-test medical-necessity criteria is considered not medically necessary.

For Wisconsin Medicaid and BadgerCare Plus members, testing is not covered when the results would not have a clinically useful impact on health outcomes.

Coding and Reference Guidance

Medicare LCD referenceHCPCS

L35000

Molecular Pathology Procedures

Prior Authorization and Provider Requirements

Prior Authorization

Commercial Prior Authorization Required

Commercial genetic, genomic, and molecular testing requires prior authorization through the Health Plan using the Genetic, Genomic and Molecular Testing Prior Authorization Request.

Prior Authorization

Medicaid Prior Authorization Required

Prior authorization is required for BadgerCare Plus and Medicaid SSI genetic, genomic, and molecular testing. Use ForwardHealth resources to confirm payable services, authorization requirements, and applicable criteria.

Consult the ForwardHealth fee schedule and Physician's Handbook for current requirements.

Unsupported block type: prior_auth

Prior Authorization

Policy Scope and Background

This policy addresses diagnostic genetic testing for disorders affecting the lungs and other respiratory conditions. Potentially covered testing includes CFTR analysis for cystic-fibrosis-related disorders, other covered lung-disorder testing, and SERPINA1 testing for alpha-1 antitrypsin-related respiratory disease. Coverage depends on the member's product, applicable clinical criteria, clinical usefulness, fee-schedule requirements, and prior authorization.

Covered Respiratory Testing Indications

Diagnostic testing for respiratory or lung disorders

Diagnostic genetic testing may be considered for disorders affecting the lungs, subject to the applicable product-specific coverage pathway.

Respiratory or lung-disorder diagnostic testing

Covered or potentially covered testing
- Diagnostic testing for cystic-fibrosis-related disorders, including CFTR sequencing and/or deletion/duplication analysis.
- CFTR intron 9 PolyT and TG analysis.
- Other covered lung-disorder genetic testing.
Coverage pathway

Eligibility Requirements

The policy does not state a specific requirement that a member undergo prior genetic testing before the covered testing described in this policy.

Excluded Services

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

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyGenetic Testing: Respiratory

Policy CodePolicy N/A

Change TypeMaterial revision

Effective DateJanuary 1, 2026

Last ReviewDec 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization for applicable respiratory genetic testing before services are performed.

SourceLink

On This Page

Medicare Advantage Prior Authorization

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

The policy states that Medicare Advantage prior authorization will be required beginning March 1, 2026; follow the applicable Health Plan process and effective date.

Documentation Required

Commercial Documentation Requirements

Submit the applicable commercial prior-authorization request with supporting clinical information needed to establish medical necessity.

Use the Genetic, Genomic and Molecular Testing Prior Authorization Request.

Documentation Required

ForwardHealth Documentation Requirements

For BadgerCare Plus and Medicaid SSI, consult the ForwardHealth Physician's Handbook for coverage, prior authorization, genetic counseling, documentation, and test-specific requirements.

Use the ForwardHealth Online Handbook pathways for covered services, prior authorization guidelines, and noncovered genetic testing.

Note

Review the TPA Plan Document

For TPA services, review the member's Summary Plan Description before requesting or rendering testing to determine coverage, limitations, and exclusions.

If the Summary Plan Description does not contain specific guidelines or criteria, groups using the Health Plan to process services follow commercial criteria.

Billing Rule

Verify Benefits

Verify the member's Schedule of Benefits and Certificate before rendering or submitting services.

Denial Risk

Failure to Meet Commercial Criteria

Commercial testing that does not meet the applicable criteria is considered not medically necessary. Testing performed for reasons outside the stated criteria is considered experimental.

Denial Risk

Medicaid Noncovered or Non-Useful Testing

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

Full genome and exome sequencing are not covered.

Denial Risk

Out-of-Network FHC Services Not Covered

Family Health Center services provided by out-of-network providers have no coverage.

Verify network status before scheduling or submitting the service.

Billing Rule

Verify SERPINA1 Fee-Schedule Coverage

For SERPINA1 Common Variant Analysis or Sequencing and/or Deletion/Duplication Analysis, verify coverage using the applicable ForwardHealth fee schedule before billing.

The fee schedule determines whether the service is covered.

Documentation Required

Consult ForwardHealth for Genetic Counseling

For genetic counseling requirements and related provider documentation, consult the ForwardHealth Physician's Handbook.

Note

No Specific Ordering Specialty Stated

The policy does not state a specific ordering-provider specialty requirement for these tests.

For Commercial members, the test must meet the applicable individual-test criteria in Concert Genetics Navigator in InterQual format.

For Wisconsin Medicaid and BadgerCare Plus members, the service must be covered under the ForwardHealth fee schedule and meet applicable clinical-usefulness and program requirements.

SERPINA1 testing for alpha-1 antitrypsin-related respiratory disease

SERPINA1 testing may be considered for alpha-1 antitrypsin-related respiratory disease when the applicable ForwardHealth coverage requirements are met.

SERPINA1 respiratory testing

Testing method
- SERPINA1 common variant analysis.
- SERPINA1 sequencing.
- SERPINA1 deletion/duplication analysis.
The applicable ForwardHealth fee schedule must identify the service as covered.
Review the ForwardHealth fee schedule to determine whether the service is covered.