Genetic Testing for Hereditary Cancer (for New Jersey Only)
Coverage criteria for genetic testing for hereditary cancer in New Jersey members, including single‑gene, BRCA1/2, and multi‑gene hereditary cancer panels; applies to providers ordering such tests for New Jersey members.
Added language indicating BRCA1/2 testing is proven and medically necessary for individuals with a personal history of breast cancer diagnosed at age 65 or younger.
Added malignant phyllodes tumors to the list of qualifying personal‑history tumor types and revised wording to specify multi‑gene hereditary cancer panel testing is proven and medically necessary when criteria are met.
Expanded family‑history based criteria to add first‑ or second‑degree relatives with triple‑negative breast cancer or male breast cancer and revised BRCA‑related relative criteria to include proband personal history of prostate cancer plus a first‑ or second‑degree relative with a BRCA‑related cancer.
Specified that certain tumor‑detected pathogenic variants (explicit gene list) merit germline testing consideration per revised policy language.
Added language that genetic testing for the purpose of polygenic risk scoring for hereditary cancers is unproven and not medically necessary for all indications.
Added CPT code 0495U to Applicable Codes and noted that CPT codes 0474U, 0475U, and 0495U are not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by New Jersey Medicaid.
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