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    v1.0.28
    OpenPayerPolicy UpdatesNephrologySecurity Health Plan Genetic Testing Update | Open…
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    CurrentSecurity Health Plan of Wisconsin, Inc.Policy N/A

    Genetic Testing: Nephrology

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    This policy governs coverage, medical necessity, and prior authorization requirements for genetic, genomic, and molecular testing used to evaluate known or suspected kidney disorders, including testing of asymptomatic potential living donors. Requirements vary by product, including Commercial, Medicaid/BadgerCare Plus, Family Health Center, Medicare Advantage, and Third Party Administration plans.

    Policy Summary
    PayerSecurity Health Plan of Wisconsin, Inc.
    PolicyGenetic Testing: Nephrology
    Policy CodePolicy N/A
    Change TypeMaterial revision
    Effective DateJanuary 1, 2026
    Last ReviewDec 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization for commercial genetic testing through the Genetic, Genomic and Molecular Testing Prior Authorization Request.
    SourceLink
    POLICY UPDATE CHANGES

    Align, Align DSNP, and Great Plains Medicare Advantage plans were added to the policy effective January 1, 2026.

    Medicare Advantage prior authorization requirements were revised so that prior authorization will be required beginning March 1, 2026.

    Medicaid and BadgerCare Plus information was updated, including coverage pathways and ForwardHealth requirements.

    RequiredPrior authorization
    2Covered Medicaid test categories

    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.

    2Medicaid fee-schedule review categories
    ExcludedMedicaid and BadgerCare Plus sequencing exclusion
    03/01/2026Medicare Advantage implementation date

    Coverage Criteria

    Commercial Clinical Authorization Criteria

    The Health Plan uses Concert Genetics Navigator in InterQual format to determine medical necessity under the applicable Commercial Clinical Authorization Criteria for the individual genetic test.

    ALL of the following

    • The requested test must meet the applicable individual-test clinical authorization criteria.
    • Specific exclusions and limitations listed under the individual test must not apply.

    Covered Medicaid Test Categories

    The following genetic testing categories are covered per the ForwardHealth fee schedule, subject to applicable clinical criteria and claim requirements.

    Covered test categories

    • Polycystic Kidney Disease Panels.
    • Comprehensive Kidney Disease Panels.

    Tests Requiring ForwardHealth Fee-Schedule Review

    For the following categories, review the ForwardHealth fee schedule to determine whether the service is covered.

    Tests requiring fee-schedule review

    • APOL1-Targeted Variant Analysis.
    • Other Covered Kidney Disorders.

    Medicare Advantage Coverage Basis

    For Medicare Advantage members, the Health Plan follows Medicare coverage requirements when an applicable Medicare policy is available.

    ALL of the following

    • The requested service is addressed by an applicable Medicare Local Coverage Determination (LCD) or National Coverage Determination (NCD), when available.

      For Align, Align DSNP, and Great Plains, prior authorization is required through the Health Plan beginning 1/1/2026.

    Third Party Administration Coverage Basis

    Third Party Administration services require prior authorization and are evaluated under the member's plan terms.

    ALL of the following

    • Prior authorization is required.
    • The member's Summary Plan Description (SPD) must be reviewed to determine whether the service is covered and whether limitations or exclusions apply.
    • If the SPD does not contain specific guidelines or criteria, the TPA group follows the Health Plan's Commercial criteria.

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

    Family Health Center services are out-of-network services and are excluded from coverage.

    Commercial testing that does not meet the applicable individual-test clinical authorization criteria is considered not medically necessary. Testing performed for any reason other than those specified 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. Clinical-usefulness determinations may use evidence-based guidelines developed and endorsed by entities such as the NCCN, ACMG, and ACOG, where published.

    Coding

    Molecular Pathology ProceduresHCPCS
    L35000Molecular Pathology Procedures

    Provider Actions

    Prior Authorization

    Obtain commercial prior authorization

    Commercial genetic testing requires prior authorization through the Genetic, Genomic and Molecular Testing Prior Authorization Request. The Health Plan uses Concert Genetics Navigator in InterQual format to determine medical necessity.

    Prior Authorization

    Submit Medicaid prior authorization

    Prior authorization is required for BadgerCare Plus and Medicaid genetic testing. Follow the ForwardHealth Physician Handbook and prior authorization guidelines for genetic testing.

    Prior Authorization

    Follow Medicare Advantage authorization dates

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

    Background

    This policy addresses genetic, genomic, and molecular testing used to evaluate known or suspected kidney disorders, including testing of asymptomatic potential living donors. Covered testing may include evaluation for inherited kidney disease and selected kidney disease panels. Coverage depends on the member's product-specific clinical criteria, whether testing is expected to produce a clinically useful impact on health outcomes, and applicable prior authorization requirements.

    Definitions

    Close relatives
    ScopeBlood relatives on the same side of the family
    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
    Policy Summary
    PayerSecurity Health Plan of Wisconsin, Inc.
    PolicyGenetic Testing: Nephrology
    Policy CodePolicy N/A
    Change TypeMaterial revision
    Effective DateJanuary 1, 2026
    Last ReviewDec 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization for commercial genetic testing through the Genetic, Genomic and Molecular Testing Prior Authorization Request.
    SourceLink
    On This Page
    Coverage CriteriaCodingProvider ActionsBackgroundDefinitions
    Prior Authorization

    Obtain TPA prior authorization

    Third Party Administration plans require prior authorization using the Genetic, Genomic and Molecular Testing Prior Authorization Request.

    Documentation Required

    Verify member benefits

    Verify the member's Schedule of Benefits and Certificate to confirm applicable benefits before proceeding with testing.

    Documentation Required

    Review ForwardHealth requirements

    For BadgerCare Plus and Medicaid, consult the ForwardHealth Physician Handbook and fee schedule for coverage, clinically useful criteria, prior authorization, genetic counseling, documentation requirements, and noncovered services.

    Documentation Required

    Review TPA plan documents

    For TPA groups, review the member's Summary Plan Description for coverage limitations and exclusions. If the SPD does not contain specific guidelines or criteria, apply the Commercial criteria.

    Denial Risk

    Meet commercial clinical criteria

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

    Denial Risk

    Document 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 an expected clinically useful impact.

    Denial Risk

    Do not bill excluded sequencing

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

    Denial Risk

    Use an in-network Family Health Center provider

    Family Health Center provides no coverage for services delivered by out-of-network providers. Confirm that the provider is within the applicable network before arranging services.