UnitedHealthcare genetic testing policy update Coverage

Coverage Criteria and Indications

BRCA1/BRCA2 and related testing

Covered when ANY of the following BRCA-related criteria are met

BRCA testing coverage: Individual with any blood relative with a known BRCA1/BRCA2 mutation.

Close blood relatives include first-, second-, and third-degree relatives on the same side of the family (see definitions).

BRCA testing coverage: Individual meeting the specified personal-history cancer criteria (see subcriteria) including breast cancer diagnosed ≤45 years; breast cancer diagnosed age 45–50 years with unknown or limited family history or a second primary breast cancer; triple-negative breast cancer diagnosed ≤60 years; male breast cancer at any age; epithelial ovarian (including fallopian tube or peritoneal) cancer at any age; exocrine pancreatic cancer; metastatic or intraductal prostate cancer; or high-grade (Gleason ≥7) prostate cancer with qualifying family history or Ashkenazi Jewish ancestry.

See chunk 4 for full enumerated personal-history criteria.

BRCA testing coverage: Individual with prior limited testing (e.g., single gene and/or absent deletion/duplication analysis) who is interested in pursuing multi-gene testing.

BRCA testing coverage: Individual with a mutation identified on tumor genomic testing that has clinical implications if also identified in the germline.

BRCA testing coverage: Individual for whom testing is intended to aid systemic therapy decision-making (for example, HER2-negative metastatic breast cancer).

BRCA testing coverage: Unaffected individual with an estimated prior probability of a BRCA1/2 pathogenic variant > 5% based on validated predictive models (e.g., Tyrer-Cuzick, BRCAPRO, Penn II).> 5% prior probability

Models referenced in policy: Tyrer-Cuzick, BRCAPRO, Penn II.

Familial Adenomatous Polyposis (APC) testing

Covered when ALL of the following are met for familial adenomatous polyposis (FAP)

FAP testing: Personal history of ≥ 20 cumulative adenomas.≥ 20 cumulative adenomas

Numeric threshold revised in 06/01/2025 policy update (replaced '> 20' with '≥ 20').

FAP testing: Or known deleterious APC mutation in a first-degree family member.

First-degree relatives defined in policy definitions.

Lynch syndrome (MMR) testing

Covered when ANY of the following Lynch syndrome criteria are met

Lynch syndrome testing: Meets Amsterdam II criteria (all Amsterdam II elements must be present: ≥3 relatives with a Lynch-associated cancer, one a first-degree relative of the other two, involvement of ≥2 successive generations, ≥1 diagnosed <50 years, FAP excluded in colorectal cancer, and tumors verified pathologically).

See chunk 9 for Amsterdam II details.

Lynch syndrome testing: Meets Revised Bethesda Guidelines (one or more Bethesda criteria such as colorectal or uterine cancer diagnosed <50 years, synchronous/metachronous Lynch-associated tumors, MSI-H histology diagnosed <60 years, or specified family-history patterns).

See chunk 10 for Revised Bethesda details.

Lynch syndrome testing: Estimated risk ≥ 5 percent for a pathogenic MMR variant based on predictive models (MMRpro, PREMM5, or MMRpredict).≥ 5% estimated risk

Predictive models named in policy: MMRpro, PREMM5, MMRpredict.

Familial Adenomatous Polyposis eligibility (revised)

Policy retired effective 04/01/2026; prior coverage criteria included revised thresholds for familial adenomatous polyposis.

FAP adenoma threshold (prior revision): Personal history of ≥ 20 cumulative adenomas.>=20 adenomas

Replaced previous wording that required 'personal history of > 20 cumulative adenomas'; policy retirement effective 04/01/2026.

Codes marked with an asterisk (*) in the code tables are not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by the Louisiana Medicaid Program. Listing a code in this policy is for reference and does not itself establish coverage or reimbursement; coverage decisions are determined by applicable federal, state, or contractual requirements and laws.

This policy was retired effective 04/01/2026. Louisiana plan membership was disenrolled on Apr. 1, 2026, and the policy is no longer applicable to Louisiana members after that date.

The presence of a procedure or PLA/CPT code in the policy is for informational purposes only and does not imply that the service represented by the code is covered or not covered. Benefit coverage and the right to reimbursement are determined by federal, state, or contractual requirements and applicable laws; codes marked with an asterisk may additionally be excluded from the State fee schedule and therefore may not be payable.

Specific Covered Indications

BRCA1/BRCA2 testing for affected and unaffected individuals meeting listed eligibility criteria; APC testing for suspected FAP; Lynch syndrome testing when Amsterdam II, Revised Bethesda, or ≥5% model risk are met; testing to clarify tumor-identified mutations for germline implications; testing to aid systemic therapy decisions in certain cancers.

Covered indications summary: BRCA1/BRCA2 testing for affected and unaffected individuals who meet the listed eligibility criteria; APC (APC gene) testing for suspected familial adenomatous polyposis when FAP criteria are met; Lynch syndrome testing when Amsterdam II, Revised Bethesda, or estimated risk ≥5% by predictive models are met; testing to clarify tumor-identified mutations that have germline implications; and testing to aid systemic therapy decisions for certain cancers.

This block summarizes covered indications referenced across policy sections.

Hereditary cancer testing as specified in the policy prior to retirement; includes familial adenomatous polyposis criteria.

Prior policy FAP criteria: Prior (pre-retirement) hereditary cancer testing policy included familial adenomatous polyposis eligibility criteria with the adenoma threshold clarified to '≥ 20 cumulative adenomas'.

Applicable Codes and Coding Notes

Applicable genetic test CPT/PLA codesmixed

*0138U	BRCA1 and BRCA2 mRNA sequence analysis (List separately in addition to code for primary procedure).
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.
*0101U	Hereditary colon cancer disorders genomic sequence analysis panel with mRNA analytics (15 genes, EPCAM and GREM1 deletion/duplication only).
*0102U	Hereditary breast cancer-related disorders genomic sequence analysis panel (17 genes).
*0103U	Hereditary ovarian cancer genomic sequence analysis panel (24 genes, EPCAM deletion/duplication only).
*0129U	Hereditary breast cancer-related genomic sequence analysis and deletion/duplication analysis (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, TP53).
*0130U	Hereditary colon cancer disorders targeted mRNA sequence analysis panel (listed separately).
*0131U	Hereditary breast cancer-related targeted mRNA sequence analysis panel (13 genes) (listed separately).

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inv-09: BRCA prior probability — > 5% (based on predictive models such as Tyrer-Cuzick, BRCAPRO, Penn II)

Threshold> 5% prior probability based on validated predictive models (e.g., Tyrer-Cuzick, BRCAPRO, Penn II)

Applicable patientsUnaffected individuals who do not otherwise meet other BRCA testing criteria but have >5% prior probability

Supporting modelsExamples cited: Tyrer-Cuzick, BRCAPRO, Penn II (Penn II)

DocumentationPrior probability should be calculated using an accepted predictive model and documented in the medical record

inv-10: cumulative adenomas threshold — ≥ 20

Threshold≥ 20 cumulative adenomas

Provider Responsibilities and Prior Authorization

Prior Authorization

Prior authorization / coverage verification

Providers should verify benefit coverage and prior authorization requirements for listed genetic test CPT/PLA codes with Louisiana Medicaid and the member's specific UnitedHealthcare plan before ordering testing. Inclusion of a code in this policy does not guarantee coverage; prior authorization requirements may vary by plan and by state.

Verify member benefits and prior authorization for genetic test CPT/PLA codes prior to ordering
Check state-specific (Louisiana) Medicaid fee schedule and plan-specific coverage
If required, obtain prior authorization before performing testing

Note

Document governing benefit terms

When applying this policy, reference the applicable federal, state, or contractual benefit plan. In the event of conflict between this Medical Policy and the member's governing benefit terms, the federal, state, or contractual requirements govern and may result in different coverage decisions.

Definitions and Reference Sources

inv-20: Close blood relatives definition

DefinitionClose blood relatives include first-, second-, and third-degree relatives on the same side of the family

First-degreeParents, siblings, children

Second-degreeGrandparents, aunts, uncles, nieces, nephews, grandchildren, half siblings

Third-degreeGreat-grandparents, great-aunts, great-uncles, great-grandchildren, and first cousins

inv-21: MCO manual

ResourceLouisiana Medicaid Managed Care Organization (MCO) Manual

Use

Not Covered / Exclusions

Codes identified with an asterisk (*) are not on the Louisiana Medicaid Fee Schedule and therefore may not be covered by the State of Louisiana Medicaid Program. Inclusion of a code in the policy is for reference only and is not a guarantee of coverage or payment; applicable benefit terms, state fee schedules, and other policies govern coverage determinations.

Not specified.

Background and Scope

Hereditary cancer syndromes such as BRCA1/2-related hereditary breast and ovarian cancer, Lynch syndrome, and familial adenomatous polyposis (APC) increase lifetime cancer risk and have important implications for surveillance, prevention, and therapy. Genetic testing can identify pathogenic germline variants to guide management for affected individuals and at-risk relatives.

Eligibility Requirements

Coverage includes individuals with a blood relative who has a known pathogenic BRCA1 or BRCA2 mutation. Also eligible are unaffected individuals who have a first- or second-degree relative meeting the policy’s listed criteria, individuals with prior limited testing seeking multi-gene evaluation, and those meeting specified personal or family history thresholds described in the BRCA-related criteria.

Individuals who previously had limited genetic testing (for example, single-gene sequencing without deletion/duplication analysis or other incomplete testing) may be eligible for expanded multi-gene testing or comprehensive analysis when the prior test was incomplete and the current testing would change clinical management; documentation of prior testing and rationale for additional testing should be provided.

OpenPayer

Genetic Testing for Hereditary Cancer (for Louisiana Only)