CurrentUnitedHealthcarePolicy CSNCT0151.01

Carrier Testing Panels for Genetic Diseases (for North Carolina Only)

UnitedHealthcare medical policy for carrier genetic testing panels that applies only to North Carolina members and provides guidance on coverage interpretation referencing the North Carolina Medicaid clinical coverage policy.

Policy Summary

PayerUnitedHealthcare

PolicyCarrier Testing Panels for Genetic Diseases (for North Carolina Only)

Policy CodePolicy CSNCT0151.01

Change TypeNew Medical Policy

Effective DateMarch 1, 2026

Next Review Date

Key ActionProvide medical record documentation that supports medical necessity, including relevant history, exam, and test results, when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

New Medical Policy

NCstate applicability

03/01/2026effective date

CSNCT0151.01policy number

NC Medicaid 1S-10primary clinical criteria source

81412,81443,81479example coding provided

Coverage Criteria

Clinical coverage (delegated)

Covered when meeting the clinical criteria specified by the North Carolina Medicaid Clinical Coverage Policy Laboratory Services: 1S-10.

Referenced criteria: Member meets all medical necessity clinical coverage criteria as defined in NC Medicaid Clinical Coverage Policy 1S-10 for genetic testing for carrier and prenatal

This UnitedHealthcare policy delegates detailed clinical eligibility and indication criteria to NC Medicaid Clinical Coverage Policy 1S-10; consult that policy for specific inclusion/exclusion, family history, counseling, and prior testing requirements.

This policy does not list any explicit test or indication exclusions. The listing of CPT codes is provided for reference only and does not imply that a service is covered or not covered; benefit coverage is determined by federal, state, or contractual requirements and applicable laws.

Coverage determinations under this policy follow applicable federal, state, and contractual requirements. This policy itself does not define specific conditions as not medically necessary; instead, medical necessity clinical criteria are determined by the referenced North Carolina Medicaid Clinical Coverage Policy (Laboratory Services: 1S-10) and by applicable benefit rules.

Covered Indications

Policy Summary

PayerUnitedHealthcare

PolicyCarrier Testing Panels for Genetic Diseases (for North Carolina Only)

Policy CodePolicy CSNCT0151.01

Change TypeNew Medical Policy

Effective DateMarch 1, 2026

Next Review Date

Key ActionProvide medical record documentation that supports medical necessity, including relevant history, exam, and test results, when requesting coverage.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions & Documentation

Note

Use of Policy

This policy document is intended to assist providers in interpreting UnitedHealthcare standard benefit plans. It does not replace the terms of the member’s federal, state or contractual benefit plan. Always check the applicable federal, state or contractual requirements for benefit plan coverage before using this policy; those requirements govern in the event of a conflict.

Use this policy as a guide to clinical coverage determination, not as a substitute for benefit plan language.
When in conflict, federal, state, or contractual requirements govern coverage decisions.

Documentation Required

Medical Records Required

Documentation supporting medical necessity may be required to determine benefit coverage. The patient’s medical record must fully support the medical necessity for the requested services and include relevant history, physical examination findings, and results of pertinent diagnostic tests or procedures. Records must be legible, maintained in the patient chart, and made available upon request.

Include relevant medical history, physical exam, and diagnostic test results.
Lack of sufficient medical record documentation may result in denial of services.

Note

Reference to Governing Clinical Criteria

Benefit coverage is determined by federal, state, or contractual requirements and applicable law. Refer to NC Medicaid Clinical Coverage Policy 1S-10 (Genetic Testing for Carrier and Prenatal) for specific medical necessity clinical coverage criteria, which may include genetic counseling and other requirements.

Check NC Medicaid 1S-10 for additional medical necessity criteria and requirements.
Where state or contractual rules differ from this policy, those rules govern.

Step Therapy

This policy does not specify any step therapy requirements for the services described. Check applicable federal, state, and contractual requirements (including NC Medicaid policy) for any plan-specific utilization management rules.

No step therapy requirements are specified in this policy document.
Verify plan-specific rules before ordering or billing.

Prior Authorization

Authorization, Ordering, and Coding Guidance

Authorization and coding guidance are not specified here; use this policy to help interpret benefit coverage but verify prior authorization, ordering provider qualifications, and coding/billing requirements with the member’s plan, state rules, and contractual provisions.

Check payer and state-specific prior authorization requirements before providing services.
Confirm who may order tests per federal, state, or contractual requirements (see NC Medicaid policy as applicable).
Ensure appropriate billing codes and modifiers are used and supported by documentation.

Definitions & Background

CLIA regulation

Regulatory authorityLaboratories that perform genetic tests are regulated under the Clinical Laboratory Improvement Amendments (CLIA) Act of 1988.

FDA approval noteFDA approval alone is not a basis for coverage (informational only).

Guidance and resourcesMore information available at the FDA IVD regulatory assistance webpage and the FDA nucleic acid–based tests list (links cited in policy).

Action for providers/labsEnsure genetic testing is performed in CLIA-regulated laboratories; verify lab CLIA status when submitting tests for coverage consideration.

This policy provides guidance specific to carrier genetic testing panels and defers detailed medical necessity clinical criteria to the North Carolina Medicaid Clinical Coverage Policy, Laboratory Services: 1S-10. Laboratories that perform genetic tests are regulated under CLIA, and FDA approval alone is not a basis for coverage; consult NC Medicaid 1S-10 for covered indications, counseling, and other clinical requirements.

OpenPayer

Carrier Testing Panels for Genetic Diseases (for North Carolina Only)

Coverage Criteria

Covered Indications

Eligibility Requirements

Applicable Coding

Provider Actions & Documentation

Not Covered / Exclusions

Definitions & Background

81412	Ashkenazi Jewish associated disorders genomic sequence analysis panel, must include sequencing of at least 9 genes (ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, SMPD1)
81443	Genetic testing for severe inherited conditions genomic sequence analysis panel, must include sequencing of at least 15 genes (e.g., ACADM, ARSA, ASPA, ATP7B, BCKDHA, BCKDHB, BLM, CFTR, DHCR7, FANCC, G6PC, GAA, GALT, GBA, GBE1, HBB, HEXA, IKBKAP, MCOLN1, PAH)
81479	Unlisted molecular pathology procedure