ModifiedUnitedHealthcarePolicy CS049ID.C

Genetic Testing for Hereditary Cancer (for Idaho Only)

State-specific medical policy governing coverage criteria for genetic testing for hereditary cancer for Idaho members, including Idaho Medicaid Plus. It details when single-gene, known mutation, and multigene panel testing are considered medically necessary and lists tests considered unproven.

Policy Summary

PayerUnitedHealthcare

PolicyGenetic Testing for Hereditary Cancer (for Idaho Only)

Policy CodePolicy CS049ID.C

Change TypeRevised coverage criteriacode list updatessequencing stance added

Effective DateJun 1, 2026

Next Review Date

Key ActionProvide complete medical record documentation (detailed family history, test rationale, and counseling notes) when requesting coverage or prior authorization.

SourceLink

POLICY UPDATE CHANGES

Revised coverage criteria for genetic testing with a Multigene hereditary cancer Panel for individuals with a personal history of a Primary Solid Tumor (excluding basal or squamous cell skin cancer), adding specific tumor-type and age/family-history triggers.

Replaced requirement referencing BRCAPro with CanRisk as an acceptable risk model (Tyrer-Cuzick, BRCAPRO, or CanRisk) for a 2.5% threshold for BRCA1/2 pathogenic variant risk.

Added language that whole-exome and whole-genome sequencing for identifying hereditary cancer syndromes is unproven and not medically necessary.

Expanded medical records documentation language clarifying that coverage is determined by federal, state, or contractual requirements and that documentation may be required to assess clinical criteria.

Updated Definitions (including Penetrance, Age Guidelines, BRCA-Related Cancers, Gleason Scoring, Lynch Syndrome-Associated Cancer, Ovarian Cancer, Personal and Family History Documentation, PREMM5, Primary Solid Tumor).

Added and removed multiple CPT/PLA and molecular codes in Applicable Codes and in sections for Multigene Panel and Whole Exome/Genome Sequencing.

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.

State-specificApplies to

5+ genesDefinition threshold

<=65BRCA1/2 age trigger

RNA/PRS/WES/WGSUnproven tests

multipleCPT/PLA codes

Coverage Criteria for Hereditary Cancer Genetic Testing

inv-01: Multigene hereditary cancer panel - medically necessary indications

Covered when ANY of the following groups of criteria are met for individuals with a personal history of cancer:

Single-gene or known-mutation testing: Single-gene testing and known mutation testing for familial cancer are medically necessary for individuals with a personal history of cancer. BRCA1/2 testing is medically necessary for individuals with breast cancer diagnosed at age 65 years or younger.

Source: Non-state-specific criteria and BRCA age threshold from policy

Personal history — tumor-specific indicators: Individual has a personal history of at least one listed tumor-specific condition such as: breast cancer diagnosed ≤50 years; metastatic breast cancer; multiple primary or bilateral breast cancers; triple-negative breast cancer; lobular breast cancer with diffuse gastric cancer personal/family history; Ashkenazi Jewish ancestry with breast cancer; breast cancer in an individual assigned male at birth; breast or prostate cancer with at least one first- or second-degree relative with a BRCA-related cancer; ovarian cancer (including fallopian tube, primary peritoneal, sex‑cord tumors with annular tubules, or hypercalcemic-type small cell carcinoma of the ovary); serous tubal intraepithelial carcinoma; pancreatic cancer; metastatic prostate cancer; Lynch syndrome–associated cancer; neuroendocrine tumors (e.g., adrenocortical carcinoma, pheochromocytoma/paraganglioma); malignant phyllodes tumors; renal cell carcinoma meeting specified age/family/histology criteria; or at least two different primary solid tumors (excluding basal or squamous cell skin cancer).

See policy enumerated list (chunks 5–7)

Personal history plus family-history indicators: Individual has a personal history of a primary solid tumor (excluding basal or squamous cell skin cancer) and a family history meeting at least one of: one close blood relative with a Lynch syndrome–associated cancer; a close blood relative diagnosed with a primary solid tumor at age ≤40; or at least two close blood relatives (in addition to the affected individual) on the same side of the family diagnosed with any primary solid tumor (excluding basal or squamous cell skin cancer).

Family-history–based criteria from policy (chunk 6)

Tumor-based or predictive-model indicators: Individual with a primary solid tumor and at least one of: a pathogenic variant detected in tumor tissue that has germline implications (examples listed in policy); tumor testing showing MSI‑high or loss of mismatch repair proteins (MLH1, MSH2, MSH6, PMS2); renal tumors with specified histologic features (see policy); Tyrer‑Cuzick, BRCAPRO, or CanRisk score ≥2.5% for BRCA1/2; or PREMM5/MMRpro/MMRpredict score ≥2.5% for Lynch syndrome (with context-specific guidance for PREMM5 use).

Tumor-testing and predictive model score criteria (chunk 7 and 63)

Pediatric cancer coverage: Genetic testing with a multigene hereditary cancer panel is medically necessary for individuals diagnosed with cancer at age 18 years or younger.

Age-based criterion (chunk 7)

inv-03: General medical necessity criteria

Covered when ALL of the following are met

General coverage prerequisites: (1) Personal or family history consistent with hereditary cancer susceptibility; (2) The requested test can be adequately interpreted (appropriate genes and methods for the clinical question); and (3) Test results can be used to diagnose or influence medical management of the individual or at‑risk family members.

Derived from policy general description and decision framework (chunks 21, 24)

inv-04: Multigene panel coverage considerations

Coverage considerations for multigene panels

Panel vs targeted testing considerations: Multigene panels may be appropriate when multiple hereditary cancer syndromes are suspected or stepwise testing is impractical; however, panels often include low‑ to moderate‑risk genes whose clinical management implications may be uncertain, which can reduce utility and increase VUS rates and downstream interventions.

Balance potential efficiency versus risk of uncertain findings and follow-up (chunks 24, 31)

inv-05: Clinically Indicated Testing (NCCN-based)

Covered when ANY of the following clinically indicated situations are met (per NCCN guidance and site-specific criteria):

General clinically indicated situations (NCCN): Any of: a blood relative with a known P/LP variant; prior limited testing (e.g., single‑gene) negative but patient still meets testing criteria and desires MGPT; a P/LP variant identified on tumor genomic testing that has germline implications; testing to inform systemic therapy or surgical decision‑making; meeting testing criteria for Li‑Fraumeni, Cowden/PTEN hamartoma tumor syndrome, or Lynch syndrome.

NCCN general criteria (chunk 47)

Breast cancer-specific clinically indicated criteria: Personal history features: diagnosed ≤50 years; testing to guide PARP inhibitor use in metastatic disease or adjuvant olaparib decisions; triple‑negative pathology; multiple primary breast cancers; lobular histology with diffuse gastric cancer history; male breast cancer; Ashkenazi Jewish ancestry; relevant affected relatives (e.g., relative diagnosed ≤50, male breast cancer relative, relative with ovarian/pancreatic/high‑risk prostate cancer); or unaffected individuals with first/second‑degree relatives meeting criteria or >5% BRCA1/2 probability by models.

NCCN breast indications (chunks 48–49)

Ovarian cancer-specific clinically indicated criteria:

inv-06: Consider/Low Probability Testing

May be considered or low probability scenarios:

May be considered — breast cancer scenarios: Patients with breast cancer age ≤65 who do not meet primary high‑penetrance criteria (moderate‑penetrance gene findings more likely); patients with certain family histories conferring intermediate risk; unaffected individuals with 2.5–5% BRCA1/2 probability by models (Tyrer‑Cuzick, BRCAPRO, CanRisk); malignant phyllodes tumors — testing may be considered with counseling.

NCCN 'may be considered' guidance (chunks 48–49)

Low probability situations: Scenarios with low likelihood (<2.5%) of identifying high‑penetrance genes such as female patients diagnosed with breast cancer >65 years without relevant family history, or localized prostate cancer Gleason <7 without relevant family history; testing is generally low yield and not routinely indicated.

NCCN low‑probability guidance (chunk 49)

inv-07: Covered indications for MGPT

Covered when any of the following guideline-aligned indications are met

CRC/EC guideline-aligned indications (NCCN): Germline MGPT is appropriate for patients with colorectal or endometrial cancer as an alternative to tumor- or family-history selection; panels should at minimum include specified CRC- or EC‑related genes (e.g., APC, MUTYH, MLH1, MSH2, MSH6, PMS2, EPCAM for CRC; MLH1, MSH2, MSH6, PMS2, EPCAM, PTEN, BRCA1/2 for EC); use of broader panels based on age, phenotype, family history, and preference.see gene lists

NCCN v1.2025 recommendations (chunk 61)

Lynch syndrome testing criteria: Testing recommended when any of: known familial LS PV; LS‑related cancer diagnosed ≤49 years; synchronous/metachronous LS‑related cancers at any age; first/second‑degree relative with LS‑related cancer diagnosed ≤49; two or more first/second‑degree relatives with LS‑related cancers; predictive model risk ≥5% (PREMM5/MMRpro) or contextually ≥2.5% for some PREMM5 uses; tumor with dMMR at any age; or P/LP variant detected on tumor testing with germline implications.PREMM5/MMRpro ≥5% (≥2.5% in some contexts)

Detailed Lynch criteria (chunk 63)

inv-08: Covered when professional guideline criteria are met

Germline multigene testing is recommended or should be offered in the following clinical contexts per referenced guidelines:

ASCO summary recommendations: All patients with cancer should have a comprehensive family history recorded; when indicated, germline testing using a multigene panel should be offered if more than one relevant gene is present and panels should include at minimum the more strongly recommended genes for the patient’s cancer type. Smaller panels can be used initially when rapid results are needed; broader panels may be ordered when benefits outweigh harms.

ASCO guideline summary (chunks 76–77)

Tumor-directed germline testing triggers: Offer germline testing when tumor testing reveals pathogenic variants in genes with potential germline implications (examples listed in ASCO guidance) regardless of tumor result in some circumstances; include at minimum strongly recommended genes for specific cancers in the germline panel.

ASCO tumor‑to‑germline recommendations (chunks 77, 79)

Cancer-specific recommended gene inclusion: For specific cancers (e.g., prostate, pancreatic, neuroendocrine, kidney), include at least the more strongly recommended genes identified by guidelines (examples: BRCA1/2, ATM, PALB2, CHEK2, MLH1/MSH2/MSH6/PMS2/EPCAM, SDHx, VHL, TP53, APC, etc.) and tailor panel composition to phenotype and family history.

inv-09: Evidence summaries

Evidence-based stance summaries

Polygenic risk scores (PRS): PRS have limited clinical utility alone (modest discrimination in some settings; e.g., pooled AUC ~0.63 for prostate cancer) and improved performance only when combined with clinical variables; ACMG does not support routine clinical implementation of PRS unless providers and patients understand limitations and how results would guide management.

ACMG caution on PRS clinical use (chunk 93)

Concurrent RNA testing: Current evidence is insufficient to support routine concurrent RNA panel testing with BRCA1/2 or multigene hereditary cancer panels; some studies show modest increases in diagnostic yield and variant reclassification but overall quality of evidence is low and impact on clinical outcomes is unclear.

RNA testing evidence summary (chunk 94)

Whole-exome/Exome+ screening: Exome+ and WES can identify carriers of HBOC and Lynch genes, including individuals who would not meet current guideline criteria (Tapestry study found 1.24% carriers and ~39% of carriers did not meet NCCN criteria), but limitations exist (missed CNVs, population representation, and uncertain downstream outcomes); broader population screening requires further study.

inv-10: Individuals With a Personal History of a Primary Solid Tumor

Revised coverage criteria for individuals with a personal history of a Primary Solid Tumor (excluding basal or squamous cell skin cancer):

Renal cell carcinoma expanded indications: Individual has renal cell carcinoma and any of: diagnosed at ≤46 years of age; diagnosed at any age with bilateral or multifocal tumors; has one or more first‑ or second‑degree relatives with renal cell carcinoma; or has a personal or family history of mesothelioma or uveal melanoma.

Policy revision added renal cell carcinoma family/age/history triggers (chunks 5, 111)

Renal cell carcinoma histology criteria: Tumors with histologic features such as multifocal papillary histology; HLRCC‑associated RCC or RCC with fumarate hydratase deficiency; Birt‑Hogg‑Dubé syndrome‑related histology; angiomyolipomas plus one additional tuberous sclerosis complex criterion; or succinate dehydrogenase‑deficient RCC histology meet criteria for MGPT consideration.

Histology‑based triggers added/clarified (chunks 7, 111)

Serous tubal intraepithelial carcinoma: Individual has serous tubal intraepithelial carcinoma.

inv-11: Sequencing approaches

Coverage stance on sequencing approaches:

WES/WGS not medically necessary for hereditary cancer identification: Whole‑exome and whole‑genome sequencing for the purpose of identifying hereditary cancer syndromes or hereditary cancer syndrome risk is unproven and not medically necessary.

Policy explicitly states WES/WGS are unproven/not medically necessary for this purpose (chunks 8, 111)

RNA panel testing, polygenic risk scoring, and whole-exome/whole-genome sequencing performed for the purpose of identifying hereditary cancer syndromes or hereditary cancer risk are considered unproven and not medically necessary for all indications. This policy explicitly lists these modalities as not supported for routine use in identifying hereditary cancer syndromes and notes the coverage stance has been updated to reflect that WES/WGS are unproven for this indication (effective 06/01/2026).

Multigene panels that would identify variants in low- to moderate-risk genes without clear, evidence-based implications for medical management may not be considered clinically useful. Inclusion of such genes increases the likelihood of variants of uncertain significance (VUS) and may lead to unnecessary follow-up testing or procedures without proven benefit; clinicians should weigh panel breadth against interpretability and actionable outcomes.

Panels that include genes lacking evidence to support a change in medical management should be used cautiously. Professional guidance emphasizes that VUS results are not clinically actionable and that genetic testing should be performed and interpreted within the context of genetic counseling or clinician expertise in cancer genetics to avoid inappropriate management decisions.

Routine population screening with genetic counseling or BRCA testing is not recommended for individuals without a personal or family history or ancestry associated with increased BRCA1/2 risk. The USPSTF recommends targeted risk assessment and counseling for those with suggestive history and recommends against routine BRCA testing in low-risk individuals.

The use of polygenic risk scores (PRS) to assess hereditary cancer risk is not supported by sufficient evidence for routine clinical use. PRS have limitations in predictive value, population generalizability, and clinical utility; professional statements (ACMG) caution that PRS should not be used clinically unless providers and patients understand the limitations and how results would guide management.

Concurrent RNA panel testing performed routinely as part of BRCA1/2 testing or multigene hereditary cancer panels is not supported by sufficient evidence. While some studies suggest RNA can clarify certain DNA variants and modestly increase diagnostic yield, existing evidence is limited in quality and does not yet demonstrate consistent impact on clinical outcomes to support routine concurrent use.

Whole-exome sequencing (WES) and whole-genome sequencing (WGS) for the purpose of identifying hereditary cancer syndromes or hereditary cancer risk are considered unproven and not medically necessary. Although exome-based approaches can identify carriers not meeting guideline criteria in research settings, limitations (e.g., incomplete detection of copy number variants, uncertain clinical utility for population screening) preclude routine clinical coverage for hereditary cancer identification.

Multigene hereditary cancer panels (MGPT) are considered medically necessary only for the specific indications enumerated in this policy; for other indications the panels are unproven and not medically necessary. The policy also reiterates limitations of concurrent RNA testing and PRS, and warns that overly broad panels that include low/moderate-risk genes without management implications may reduce clinical utility.

Use of broad panels is discouraged when results cannot be reliably interpreted or will not influence clinical management. Large multisyndrome or pan-cancer panels increase the chance of VUS findings and may include genes lacking evidence for actionable interventions; targeted or stepwise testing may be preferred when a single syndrome is most likely.

Routine genetic counseling or BRCA testing is not recommended for individuals without a personal or family history or ancestry associated with increased BRCA1/2 risk. When testing is indicated by history or screening tools, pre-test counseling and informed decision-making are recommended; testing unaffected individuals should generally follow testing of an affected relative when possible.

Ordering broad multisyndrome panels without clinical justification or guideline and outcome support is discouraged. Evidence reviews found minimal or unclear support for multisyndrome panels to change clinical management, and professional societies recommend selecting panels tailored to the suspected syndrome and patient phenotype.

The ACMG does not support routine clinical implementation of PRS unless providers and patients thoroughly understand the limitations, population-dependence, and uncertain implications for management. PRS should not be used in isolation to guide interventions and require clear, evidence-based pathways linking score results to clinical action.

Whole-exome and whole-genome sequencing for identifying hereditary cancer syndromes or hereditary cancer syndrome risk is not supported for routine clinical use. Although research exome/exome+ studies identify some carriers outside guideline-based testing, current limitations and uncertain downstream clinical utility mean these approaches remain unproven for this purpose.

inv-02: Not medically necessary / Unproven tests

Unproven / Not medically necessary tests: Multigene hereditary cancer panels are unproven and not medically necessary for indications other than those explicitly listed. RNA panel testing, polygenic risk scoring for hereditary cancer, and whole‑exome/whole‑genome sequencing for identifying hereditary cancer syndromes or risk are unproven and not medically necessary for all indications.

Explicit exclusions per policy (chunks 8, 24)

Specific Covered Indications and Eligibility

inv-77: Single-gene and known mutation testing; BRCA1/2 for breast cancer diagnosed <=65; MGPT for listed indications; pediatric panels covered

Covered single-gene and MGPT scenarios: Single‑gene and known mutation testing for familial cancer in individuals with a personal history of cancer are covered. BRCA1/2 testing is covered for breast cancer diagnosed at age ≤65. Multigene hereditary cancer panels are covered when personal history meets listed tumor‑specific, family‑history, tumor‑testing, or predictive‑model score criteria; multigene panels are covered for individuals diagnosed with cancer at age ≤18.

Summary of covered indications (chunks 4–7)

inv-110: Not covered / Unproven summary

Unproven/uncovered tests summary: RNA panel testing, polygenic risk scoring, and whole‑exome/whole‑genome sequencing for the purpose of identifying hereditary cancer syndromes or risk are considered unproven and not medically necessary for routine use; use of broad panels that include genes without clear management implications should be approached cautiously and may not be covered when not clinically justified.

Policy exclusions and caution regarding broad panels (chunks 8, 24)

Provider Actions, Authorization, and Documentation Requirements

Documentation Required

Medical records for review — Medical records documentation may be required

Medical records documentation may be required to assess whether the member meets clinical criteria for coverage. The patient's medical record must contain documentation that fully supports medical necessity (relevant medical history, physical exam, results of pertinent tests) and must be made available upon request. Lack of adequate documentation may lead to denial.

Medical records must be legible and contemporaneous.
Documentation should include history and physical, test results, and pedigree when applicable.

Prior Authorization

Prior authorization may be required — Claims for WES/WGS and MGPT CPT/HCPCS codes should be supported by documentation

Prior authorization may be required for certain tests (for example, whole-exome/whole-genome sequencing and some multigene panel tests). Claims for WES/WGS and MGPT CPT/HCPCS codes should be supported by documentation demonstrating medical necessity and, where applicable, that testing meets guideline-based indications.

Applicable Codes and Coding Notes

BRCA1 and BRCA2CPTCovered

81162	BRCA1 and BRCA2 gene analysis; full sequence analysis and full duplication/deletion analysis
81163	BRCA1 and BRCA2 gene analysis; full sequence analysis
81164	BRCA1 and BRCA2 gene analysis; full duplication/deletion analysis
*0138U	BRCA1 and BRCA2 mRNA sequence analysis (list separately)

Multi-Gene Panels (CPT/PLA/Proprietary)CPT

*0101U	Hereditary colon cancer disorders panel (15 genes sequencing and del/dup; EPCAM and GREM1 del/dup only)
*0102U	Hereditary breast cancer-related disorders panel (17 genes sequencing and del/dup)
*0103U	Hereditary ovarian cancer panel (24 genes sequencing and del/dup; EPCAM del/dup only)
*0129U	Hereditary breast cancer-related disorders panel (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, TP53)
*0130U	Targeted mRNA sequence analysis panel for hereditary colon cancer disorders (listed genes) (list separately)
*0133U	Targeted mRNA sequence analysis panel for hereditary prostate cancer-related disorders (11 genes) (list separately)
*0134U	Targeted mRNA sequence analysis panel for hereditary pan-cancer (18 genes) (list separately)
*0162U	Hereditary colon cancer (Lynch syndrome) targeted mRNA sequence analysis panel (MLH1, MSH2, MSH6, PMS2) (list separately)
*0238U	Oncology (Lynch syndrome) genomic DNA sequence analysis of MLH1, MSH2, MSH6, PMS2, and EPCAM
*0474U	Hereditary pan-cancer 88-gene genomic sequence analysis panel with duplications/deletions

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Whole Exome / Whole Genome and Related ProceduresCPTCovered

*0212U	Whole genome and mitochondrial DNA sequence analysis for rare constitutional/heritable disorders, proband
*0213U	Whole genome and mitochondrial DNA sequence analysis for rare constitutional/heritable disorders, each comparator genome
*0214U	Whole exome and mitochondrial DNA sequence analysis for rare constitutional/heritable disorders, proband
*0215U	Whole exome and mitochondrial DNA sequence analysis for rare constitutional/heritable disorders, each comparator exome
*0265U	Whole genome and mitochondrial DNA sequence analysis for rare constitutional and other heritable disorders, multiple specimen types
*0266U	Tissue-specific whole-transcriptome gene expression by next-generation sequencing, reported as splicing/expression changes
81415	Exome sequence analysis (proband)
81416	Exome sequence analysis, each comparator exome (list separately)
*81417	Re-evaluation of previously obtained exome sequence
81425	Genome sequence analysis (proband)

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State Coverage Notesmixed

*	Codes marked with an asterisk (*) are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by the State of Idaho Medicaid Program — see Idaho Medicaid Provider Handbook for non-covered and excluded services.

Panel and Gene References; Key Values

Multigene PanelDefinition: For this policy, a Multigene Panel consists of five or more genes.

Predictive Model Risk ThresholdPREMM5/MMRpro: recommended thresholds include ≥5% for MMR PV; when no personal CRC/EC history, ≥2.5% may be considered with clinical judgement.

Adenomatous Polyposis ThresholdTesting recommended for patients with ≥20 cumulative adenomas; consideration for 10–19 adenomas in certain contexts.

BRCA1/2 Predicted Risk ThresholdTyrer-Cuzick, BRCAPRO, or CanRisk: ≥2.5% for BRCA1/2 predicted risk to consider testing.

Not Covered / Experimental and Unproven Tests

RNA panel testing, polygenic risk scoring (PRS), and whole-exome/whole-genome sequencing performed specifically to identify hereditary cancer syndromes or hereditary cancer risk are not covered — they are stated as unproven and not medically necessary for the listed indications. Additionally, codes labeled with an asterisk are noted as not being on the State of Idaho Medicaid Fee Schedule and therefore tests billed under those codes may not be covered for Idaho Medicaid members.

Codes marked with an asterisk (*) are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by Idaho Medicaid; tests billed under those codes could be excluded from coverage for Idaho Medicaid members and should be verified against the state fee schedule.

Routine population BRCA testing or genetic testing in individuals without a relevant personal or family history or ancestry-associated risk is not recommended and therefore not covered under this policy. Screening and testing should be directed by risk assessment tools and appropriate genetic counseling.

Panels that include genes without evidence of impacting medical management may be considered not covered. When panel composition includes genes of unclear clinical utility, testing may not meet criteria for coverage due to limited actionability and potential for uncertain results.

Multisyndrome or very broad panels used without specific clinical justification or evidence demonstrating impact on management may not be covered. Evidence reviews show minimal guideline or outcome support for indiscriminate use of broad multisyndrome testing.

Polygenic risk scores (PRS) for hereditary cancer risk are considered to have insufficient evidence to support routine clinical use and are therefore not covered in this policy for identifying hereditary cancer risk.

Definitions and Key Terms

Multigene Panel — definition for MGPT used in policy (>= 5 genes)

Operational definition of MGPTMultigene Panel: genetic tests using next‑generation sequencing that test multiple genes simultaneously; for this policy, consists of five or more genes (>= 5 genes).

Typical assay componentsMGPT usually includes sequencing of coding regions and often large deletion/duplication (copy number) analysis as part of the panel.

SynonymsAlso referred to as multigene test or multiple‑gene Panel test in the NCI Dictionary of Genetics Terms and policy text.

BRCA-Related Cancers — definition listing relevant cancer types

Cancer types includedBRCA‑Related Cancers include breast cancer; ovarian/fallopian tube/primary peritoneal cancer; pancreatic adenocarcinoma; and prostate cancer.

Breast cancer definition

Background and Rationale

Hereditary cancer testing includes single-gene testing, known mutation/familial testing, and multigene panels that use next-generation sequencing to evaluate multiple genes concurrently. Multigene panels can be useful when multiple syndromes are suspected but may include low- and moderate-risk genes; selection of the appropriate test should consider interpretability, potential to change management, and availability of genetic counseling.

Revision History and Policy Changes

2026-06-01material_revisionLatest

Revised coverage criteria for individuals with a personal history of a primary solid tumor: added serous tubal intraepithelial carcinoma, expanded renal cell carcinoma indications and histology-based triggers, updated ovarian cancer examples, and replaced PENN11 with CanRisk as an accepted BRCA risk model; added statement that WES/WGS for identifying hereditary cancer syndromes is unproven and not medically necessary.

administrative

Added language clarifying medical records documentation requirements for coverage determinations (medical records may be required to assess clinical criteria and must support medical necessity).

Policy Summary

PayerUnitedHealthcare

PolicyGenetic Testing for Hereditary Cancer (for Idaho Only)

Policy CodePolicy CS049ID.C

Change TypeRevised coverage criteriacode list updatessequencing stance added

Effective DateJun 1, 2026

Next Review Date

Key ActionProvide complete medical record documentation (detailed family history, test rationale, and counseling notes) when requesting coverage or prior authorization.

SourceLink

On This Page

Personal history of epithelial ovarian, fallopian tube, or primary peritoneal cancer at any age; certain nonepithelial ovarian cancers (e.g., sex‑cord tumors with annular tubules, hypercalcemic small cell carcinoma); or unaffected individuals with a first/second‑degree relative with epithelial ovarian cancer or >5% BRCA1/2 probability by models.

NCCN ovarian indications (chunk 50)

Pancreatic cancer-specific clinically indicated criteria: Personal history of exocrine or neuroendocrine pancreatic cancer; first‑degree relative with exocrine pancreatic cancer; or presence of neuroendocrine pancreatic tumor.

NCCN pancreatic indications (chunk 51)

Prostate cancer-specific clinically indicated criteria: Personal history with metastatic or high/very‑high risk disease; family/ancestry features including relatives with early breast cancer, male breast cancer, ovarian, pancreatic, or metastatic/high‑risk prostate cancer; multiple affected relatives or Ashkenazi Jewish ancestry; or unaffected/affected individuals with a first‑degree relative meeting criteria.

NCCN prostate indications (chunk 52)

Adenomatous polyposis testing: Testing recommended for patients with ≥20 cumulative adenomas, known familial PV in an adenomatous polyposis gene, or select clinical features (e.g., congenital hypertrophy of retinal pigment epithelium); testing may be considered for 10–19 adenomas or related tumors; consider germline testing when tumor‑only APC PV is found and other criteria met.>=20 adenomas (recommended); 10–19 may be considered

Adenomatous polyposis criteria (chunk 64)

ASCO/NCCN cancer-specific gene recommendations (chunks 79, 83–87)

Exome+ evidence summary (chunk 96)

Added to coverage criteria (chunks 5, 111)

Risk-model threshold for BRCA1/2: Individual has a Tyrer‑Cuzick, BRCAPRO, or CanRisk score of 2.5% or greater for a BRCA1/2 pathogenic variant.>=2.5%

Policy revised to replace PENN11 with CanRisk in acceptable models (chunk 7 and 111)

inv-79: Patients meeting NCCN general or site-specific clinically indicated testing criteria

Meet NCCN clinically indicated criteria: Patients meeting NCCN general or site‑specific clinically indicated testing criteria (breast, ovarian, pancreatic, prostate, colorectal/LS‑associated) are eligible for MGPT when the specific NCCN conditions are met, including tumor features, family history, prior testing status, and therapy‑related indications.

NCCN general and site‑specific criteria (chunks 47, 48)

inv-80: Patients with colorectal cancer when MGPT may identify clinically actionable P/LP variants

CRC patients when MGPT may identify actionable variants: Patients with colorectal cancer when MGPT may identify clinically actionable pathogenic/likely pathogenic variants are covered; studies demonstrate clinically actionable P/LP variant yields across ages and panel sizes supporting broader MGPT use in CRC cohorts.

Evidence and NCCN support for CRC MGPT (chunks 55, 61)

inv-81: Patients with CRC or EC meeting NCCN/Lynch criteria, adenomatous polyposis thresholds, PPGL, pancreatic cancer, and selected solid tumor patients

CRC/EC and related indications: Patients with colorectal cancer (CRC) or endometrial cancer (EC) and other Lynch syndrome‑associated cancers meeting NCCN/Lynch testing criteria; patients with adenomatous polyposis meeting adenoma count or family criteria; patients with pheochromocytoma/paraganglioma (PPGL); pancreatic cancer patients; and selected solid tumor patients per guideline indications are eligible for MGPT per specific gene lists and thresholds.see Lynch and adenoma thresholds

NCCN gene lists and thresholds (chunks 61, 63, 64)

inv-82: Patients with cancer when testing would impact treatment, trial eligibility, management of other cancer risk, or familial risk

Testing when it impacts care (ASCO/NCCN): Patients with cancer for whom germline testing would impact treatment selection, clinical trial eligibility, management of risk for other cancers, or familial risk should be offered MGPT; panels should include at minimum the more strongly recommended genes for the cancer type as specified by guidelines.

ASCO and NCCN guidance summarized (chunks 76, 77, 83–85, 87)

inv-83: Germline Exome+ sequencing to identify carriers of HBOC and Lynch syndrome genes

Germline Exome+ detection summary: Exome+ sequencing can identify carriers of HBOC and Lynch syndrome genes, including individuals who would not meet current NCCN testing criteria; in the Tapestry cohort 1.24% were carriers and ~39% of carriers did not meet NCCN criteria, suggesting broader detection but with limitations and need for further study.

Exome+ evidence from Tapestry (chunk 96)

inv-84: Individuals with a personal history of a primary solid tumor meeting specified tumor-specific, age, family history, or histologic criteria

Primary solid tumor coverage — tumor/age/family/histology criteria: Individuals with a personal history of a primary solid tumor (excluding basal or squamous cell skin cancer) meeting tumor‑specific, age, family history, or histologic criteria (including expanded RCC criteria and serous tubal intraepithelial carcinoma) are eligible for MGPT as enumerated in policy.

See detailed criteria in policy (chunks 5–7, 111)

Provide medical records and pedigree to support the request.
Codes marked with an asterisk (*) may not be covered by Idaho Medicaid (see State fee schedule note).

Documentation Required

Panel composition and genetic expertise — Testing should include at minimum strongly recommended genes and involve genetics expertise

When ordering multigene panels, ensure the panel includes at minimum the genes strongly recommended for the patient’s cancer type and that testing and interpretation involve genetics expertise. Providers should offer or involve professional genetic counseling (pre- and post-test) and document counseling in the medical record.

Select panels that at least include recommended high-penetrance genes for the suspected syndrome (NCCN/ASCO lists).
Document that genetic counseling was offered and/or provided and include counseling notes in the record.
When panels include genes of uncertain utility, document rationale for inclusion and plan to mitigate potential harms from uncertain results.

Note

Prior authorization not specified for PRS, concurrent RNA testing, or exome sequencing — no explicit prior authorization requirements described

No explicit prior authorization process is specified for polygenic risk scores (PRS), concurrent RNA testing, or exome sequencing in this policy text; however, clinical appropriateness and documentation requirements still apply. For tests and codes subject to State fee schedule exclusions, coverage may be limited.

PRS, RNA testing, and exome sequencing may not have specific prior authorization steps listed here, but medical necessity documentation is required.
Codes with an asterisk (*) are not on the Idaho Medicaid Fee Schedule and therefore may not be covered.

Billing Rule

State fee schedule and potential prior auth impact — Certain CPT/PLA and molecular codes may not be covered

Codes labeled with an asterisk (*) are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by the State of Idaho Medicaid Program. Verify state-specific coverage and prior authorization requirements before ordering.

Refer to the Idaho Medicaid Provider Handbook for non-covered and excluded services.
Examples of newly noted non-fee-schedule codes are listed in the policy (see Applicable Codes/Policy History).

Documentation Required

Panel selection and counseling — Family history and counseling documentation required

Panel selection should be guided by the patient's personal and family history, the indication for testing, and available guideline recommendations. Offer genetic counseling and document that counseling was offered; include detailed family history (pedigree), prior testing results, and the clinical rationale for panel choice.

Provide a pedigree drawing/diagram using standardized nomenclature as part of the contemporaneous medical records.
Document prior testing (including affected relative results) and how the chosen panel addresses the clinical question.
Note counseling was provided or offered; include informed consent discussion of benefits, limitations, and possible outcomes (VUS, uncertain findings).

Denial Risk

PRS clinical use caution — ACMG does not support clinical implementation of PRS without thorough understanding

PRS tools have limited evidence of clinical utility. Providers and patients must understand PRS limitations, population-specific derivation concerns, and that management changes based solely on PRS are not generally supported currently. Discuss limitations during counseling and document that discussion.

Avoid using isolated PRS testing when a monogenic etiology is suspected.
Document informed discussion of PRS limitations and how results might (or might not) affect management.

Documentation Required

Pedigree requirement — Personal and family history documentation should be provided as a pedigree

Personal and family history documentation should be provided as a pedigree drawing/diagram using standardized nomenclature and included in the contemporaneous medical records submitted with the testing request.

Pedigree should include first-, second-, and third-degree relatives, ages at diagnosis/onset, primary cancer sites, bilateral disease, and current age or age at death.
Include any relevant non-cancer features and prior genetic testing results for family members.

Documentation Required

Required clinical documentation — Detailed family history and prior testing evidence required

Required clinical documentation includes detailed personal and family history (pedigree), prior genetic testing evidence, physical examination findings, and indication for testing. Documentation must support that the test result can influence medical management or cascade testing of relatives.

Include prior probability model scores when used (e.g., PREMM5, BRCAPRO, BOADICEA) and any tumor testing results (dMMR/MSI) that prompted germline testing.
If testing is requested to guide treatment (e.g., PARP inhibitor use), document the treatment decision context and urgency.

Documentation Required

Required documentation and counseling — Documentation should include counseling and informed consent

Documentation should demonstrate that professional genetic counseling was offered and/or provided, that informed consent was obtained, and that the limitations, benefits, and possible outcomes (including VUS) were discussed.

Counseling notes should be included in the medical record and indicate whether the patient accepted counseling or declined.
For complex cases or large panels, document referral to or involvement of a certified genetic counselor or other genetics professional.

Documentation Required

Indication and counseling documentation — Documentation should support specific indication and that professional genetic counseling was offered

Documentation supporting the indication for testing must state the specific clinical reason and show that genetic counseling was offered. For tumor-derived variants with germline implications, include tumor testing findings and rationale for germline follow-up.

State whether testing is for diagnosis, treatment decision-making, cascade testing, or clarification of prior inconclusive results.
If tumor testing identified a variant with potential germline significance, include tumor report and explain implications for germline testing.

Note

Stepwise vs panel testing — Consideration of stepwise testing vs MGPT

Stepwise testing (single-gene or small-panel testing) is preferred when a single syndrome is most likely; multigene panels are appropriate when multiple syndromes are plausible or when prior limited testing was negative and suspicion remains. Panels may be cost-effective in some family scenarios but can increase detection of VUS and low-actionability findings.

Consider testing an affected relative first to maximize informative yield before testing an unaffected individual.
Document rationale when choosing panel testing over stepwise/single-gene testing.

Documentation Required

Test affected relative first — When possible, testing an affected relative first is preferred

When possible, test an affected relative first rather than an unaffected individual; this approach increases the likelihood of identifying an informative variant to guide testing of other family members.

If an affected relative is unavailable, document attempts to obtain affected-relative samples and the clinical reasoning for testing an unaffected person.
Include prior affected-relative test results in the submission when available.

Note

Targeted testing vs MGPT — Targeted testing preferred when single syndrome likely; MGPT used when multiple syndromes plausible

Targeted single-gene testing is preferred when a single hereditary syndrome is clearly suspected. Multigene panel testing (MGPT) is preferred when multiple syndromes are plausible or when prior targeted testing was limited or negative and suspicion persists.

Document the clinical features that support targeted testing vs MGPT selection.
When MGPT is chosen, document that the panel includes genes relevant to the phenotype and that genetic expertise was involved.

Step Therapy

Sequential/smaller-panel-first approach — Consider smaller targeted panels initially when rapid results needed

When rapid results are needed for treatment decisions, consider ordering a smaller targeted panel first and follow with broader panels if clinically indicated. Document the stepwise plan and clinical urgency in the record.

Smaller panels can provide faster turnaround for immediate treatment implications (e.g., PARP inhibitor eligibility).
If ordering sequential testing, include plan for reflex or additional testing if initial results are negative or inconclusive.

Step Therapy

Step therapy — Not applicable; no step therapy requirements described for RNA testing

Step therapy is not applicable for RNA testing per this policy; there are no described step therapy requirements for RNA testing. However, documentation requirements and clinical appropriateness still apply.

If RNA testing is pursued to clarify DNA variants, include both DNA and RNA results and document how RNA results changed interpretation or management.

Routine concurrent RNA panel testing performed alongside BRCA1/2 or multigene hereditary cancer panel testing is not supported by the current evidence base and is listed as not covered for routine use; isolated high-quality evidence demonstrating clinical benefit is lacking.

Whole-exome and whole-genome sequencing to identify hereditary cancer syndromes are not covered and considered not medically necessary for this indication due to remaining uncertainties about clinical utility, limitations in variant detection, and lack of demonstrated benefit for routine hereditary cancer identification.

Breast cancer includes invasive carcinomas or noninvasive (in situ) ductal carcinoma types as used in guideline references.

Use in testing criteriaThese cancer types are used to define indications for BRCA1/2 and related hereditary cancer testing per NCCN guidance.

Risk assessment tools — definition and examples (BRCAPRO, BOADICEA, PREMMplus)

Definition of risk assessment toolsStatistical or prediction tools used to estimate probability of carrying a hereditary cancer gene based on personal and family history.

Examples providedExamples include BRCAPRO, BOADICEA, and PREMMplus (policy also references Tyrer‑Cuzick, CanRisk, MMRpro, and PREMM5 elsewhere).

Intended useUsed to inform selection for genetic testing when combined with family history and clinical features.

Multigene hereditary cancer panel (MGPT) — definition and components (sequencing, rearrangement analysis)

MGPT definition and componentsMultigene hereditary cancer panel (MGPT) concurrently analyzes multiple genes associated with hereditary cancer risk, typically using next‑generation sequencing plus deletion/duplication analysis.

Laboratory considerationsTesting should include full gene sequencing and deletion/duplication analysis and be performed in an appropriately accredited genetic testing laboratory.

Clinical rationaleMGPT may be more efficient than stepwise single‑gene testing when multiple syndromes are possible, but inclusion of low/moderate‑risk genes can reduce interpretability.

MGPT (multigene panel testing) — alternate phrasing and definition

Alternate phrasing of MGPTMGPT (multigene panel testing) refers to next‑generation sequencing‑based testing that examines multiple cancer susceptibility genes concurrently, often including sequencing and deletion/duplication analysis in an accredited laboratory.

Appropriate applicationNSGC and ACMG endorse MGPT when clinically warranted and appropriately applied, with attention to test validity and clinical utility.

Counseling importanceProviders should discuss implications, limitations, and cascade testing with patients prior to MGPT.

P/LP variant — definition of pathogenic/likely pathogenic germline variant

Definition of P/LP variantA pathogenic or likely pathogenic germline variant in a cancer susceptibility gene associated with increased cancer risk or clinical actionability.

Clinical implicationsDetection of a P/LP variant should prompt discussion of medical management options and cascade testing of family members per guideline recommendations.

Testing requirementMGPT should include methods (sequencing and deletion/duplication analysis) sufficient to detect P/LP variants in targeted genes.

Lynch syndrome (LS) — definition including MMR genes and EPCAM deletions

Lynch syndrome genetic definitionLynch syndrome is defined by germline heterozygous pathogenic/likely pathogenic variants in mismatch repair genes MLH1, MSH2, MSH6, PMS2, or 3' EPCAM deletions.

Associated cancersAssociated with increased risk of colorectal, endometrial, gastric, ovarian, pancreatic, urothelial, brain, biliary, small intestinal, and sebaceous skin neoplasms.

Testing triggersClinical criteria and predictive model scores (e.g., PREMM5/MMRpro) are used to identify individuals who should be evaluated for LS.

Policy noteA PREMM5 score of ≥2.5% may be used in some contexts per policy guidance for selection for MMR testing.

Polygenic risk score (PRS) — definition of PRS and its components

Definition of PRSA polygenic risk score (PRS) is an evaluation of risk based on the combined effect of many genetic variants (SNPs), including variants with and without known gene associations.

Limitations notedEvidence to support clinical use of PRS for hereditary cancer risk is currently insufficient; ACMG does not support routine clinical implementation without thorough understanding of limitations.

Clinical use guidancePRS should not be used in isolation for suspected monogenic conditions and results require careful interpretation within clinical context.

Polygenic Risk Score (PRS) — additional definitional text and clarification

Additional PRS clarificationPRS aggregate multiple SNP effects to estimate predisposition to a condition, but predictive value varies by population and clinical context.

ACMG stanceACMG recommends against routine clinical implementation of PRS unless providers and patients understand limitations and how results will guide care.

Population concernsPRS may have reduced validity in populations different from those used to derive the score; clinical utility is limited at present.

Concurrent RNA panel testing — definition and intent

Concurrent RNA panel testing — definitionRNA‑based sequencing performed alongside DNA testing to assess splicing and transcript effects, potentially clarifying variants of uncertain significance.

Intended intentUsed to increase diagnostic yield or reclassify variants detected by DNA testing, though evidence for routine concurrent use is insufficient.

Policy positionThe policy states there is insufficient evidence to support routine concurrent RNA panel testing with BRCA1/2 or MGPT.

Exome+ / WES — definition and scope for germline screening

Exome+ / WES definitionSequencing of coding regions (exome) used for germline screening to detect single‑nucleotide variants and small indels associated with hereditary cancer risk; Exome+ may include additional analysis and interpretation workflows.

LimitationsWES/Exome+ may miss some copy number variants and noncoding variants; laboratory regulation under CLIA applies and FDA information is informational only.

Policy stanceWhole‑exome and whole‑genome sequencing for identifying hereditary cancer syndromes is considered unproven and not medically necessary for routine use per the policy.

Definitions updated — list of updated definition topics

Definitions updated — topicsDefinitions updated in this revision include: Penetrance; Age Guidelines; BRCA‑Related Cancers; Gleason Scoring; Lynch Syndrome‑Associated Cancer; Ovarian Cancer; Personal and Family History Documentation; PREMM5; Primary Solid Tumor; and others.

Policy history noteThe policy history (06/01/2026) documents updates to multiple definitions and to applicable coding lists; reviewers should refer to Policy History for details.

Impact on criteriaUpdated definitions affect thresholds and acceptable predictive models (e.g., CanRisk added as acceptable BRCA model in place of PENN11).

administrative

Updated definitions (Penetrance, Age Guidelines, BRCA-Related Cancers, Gleason Scoring, Lynch Syndrome-Associated Cancer, Ovarian Cancer, Personal and Family History Documentation, PREMM5, Primary Solid Tumor) and modified applicable codes list (removed some CPT codes and added/annotated others regarding Idaho Medicaid fee schedule).

material_revision

Added and removed multiple CPT/PLA and molecular codes for multigene panels and WES/WGS and noted several codes are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered.