CurrentUnitedHealthcarePolicy CS049OH.D

Genetic Testing for Hereditary Cancer (Ohio Only)

Defines UnitedHealthcare Ohio coverage for genetic testing related to hereditary cancer, including when testing is medically necessary and which tests/codes are applicable; applies to Ohio Medicaid determinations under OAC 5160-1-01.

Policy Summary

PayerUnitedHealthcare

PolicyGenetic Testing for Hereditary Cancer (Ohio Only)

Policy CodePolicy CS049OH.D

Change TypeCode additions, removals, and description revisions

Effective DateJun 1, 2025

Next Review Date

Key ActionDocument InterQual-directed clinical criteria and obtain prior authorization when required; ensure pre-test genetic counseling is documented.

SourceLink

POLICY UPDATE CHANGES

Added CPT codes 0495U, 81441, and 81479 to the applicable codes list.

Removed CPT codes 81433, 81436, and 81438 from the applicable codes list.

Revised descriptions for CPT codes 81432, 81435, and 81437.

Ohio-onlygeographic applicability

InterQual-basedprimary clinical criteria source

NMNRNA panel testing stance

<=18pediatric panels covered

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Coverage and Medical Necessity Criteria

Medical necessity criteria

Covered when ALL of the following are met

General coverage: Single gene testing and known familial mutation testing for familial cancer are proven and medically necessary.

InterQual-directed testing: Genetic testing for hereditary cancer is medically necessary when clinical coverage criteria in InterQual CP: Molecular Diagnostics (BRCA1/BRCA2, Hereditary Prostate Cancer, PPGL, Lynch Syndrome, and Multi-Gene Panels for Hereditary Breast/Colorectal/Ovarian Cancer Syndromes) are met.

Panel exceptions: Multi-gene hereditary cancer panels are proven and medically necessary for individuals diagnosed with cancer at age 18 or younger.

UnitedHealthcare considers multi-gene hereditary cancer panels to be proven and medically necessary only for individuals diagnosed with cancer at age 18 or younger. For all other indications, multi-gene hereditary cancer panels are described in the policy as unproven and not medically necessary and therefore are not covered under this policy.

The policy states that RNA (mRNA) panel testing for hereditary cancers is considered unproven and not medically necessary for all indications. There is a pediatric exception for multi-gene germline panels (covered when the individual was diagnosed with cancer at age ≤18), but no such exception is provided for RNA panel testing in the policy.

Specific Covered Indications

Single gene, known familial mutation testing and InterQual-specified genetic testing

Covered when ALL of the following are met

Single-gene and known familial mutation testing: Single gene testing and testing for a known familial pathogenic variant are proven and medically necessary when indicated.

InterQual-specified genetic testing: Genetic testing meeting InterQual CP: Molecular Diagnostics criteria for BRCA1/BRCA2, Lynch syndrome, Hereditary Prostate Cancer, and Hereditary Pheochromocytoma and Paraganglioma (PPGL) is medically necessary when InterQual clinical criteria are satisfied.

Multi-gene panels for pediatric diagnoses: Multi-gene hereditary cancer panels are proven and medically necessary for individuals diagnosed with cancer at age 18 or younger.

Applicable Codes and Coding Details

Applicable CPT/HCPCS/Panel Codesmixed

0138U	BRCA1/BRCA2 mRNA sequence analysis (list separately)
81162	BRCA1/BRCA2 full sequence analysis and full duplication/deletion analysis
81163	BRCA1/BRCA2 full sequence analysis
81164	BRCA1/BRCA2 full duplication/deletion analysis
0101U	Hereditary colon cancer disorders genomic sequence analysis panel (15 genes + EPCAM/GREM1)
0102U	Hereditary breast cancer-related disorders genomic sequence analysis panel (17 genes)
0103U	Hereditary ovarian cancer genomic sequence analysis panel (24 genes)
0129U	Hereditary breast cancer-related genomic sequence and del/dup panel (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, TP53)
0130U	Hereditary colon cancer targeted mRNA sequence analysis panel (10 genes) (list separately)
0131U	Hereditary breast cancer-related targeted mRNA sequence analysis panel (13 genes) (list separately)

1–10 of 24

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IBMFS panel minimum gene count requirement

Required minimum gene countInherited bone marrow failure syndromes (IBMFS) sequence analysis panel must include sequencing of at least 30 genes (e.g., BRCA2, BRIP1, DKC1, FANCA, FANCB, FANCC, FANCD2, FANCE, FANCF, FANCG, FANCI, FANCL, GATA1, GATA2, MPL, NHP2, NOP10, PALB2, RAD51C, RPL11, RPL35A, RPL5, RPS10, RPS19, RPS24, RPS26, RPS7, SBDS, TERT, TINF2)

Associated CPT code81441 — Inherited bone marrow failure syndromes sequence analysis panel (must include ≥30 genes)

Example included genesBRCA2; PALB2; FANCA; FANCD2; GATA2; RPS19; TERT (among others included in the 30+ gene list)

Member Eligibility Requirements

Coverage decisions reference InterQual CP: Molecular Diagnostics modules (BRCA1/BRCA2, Hereditary Prostate Cancer, PPGL, Lynch Syndrome, and multi-gene panels for hereditary breast/colorectal/ovarian cancer syndromes). Providers should follow InterQual clinical coverage criteria when determining medical necessity for hereditary cancer genetic testing.

Pre-test genetic counseling is strongly recommended to inform the person being tested about the advantages and limitations of the test. The policy also indicates that single-gene testing and testing for a known familial pathogenic variant are established as medically necessary when indicated.

Provider Requirements, Authorization, and Documentation

Prior Authorization

InterQual-based Prior Authorization / Medical Necessity

Coverage requires meeting InterQual clinical criteria. Services stated as unproven or subject to coverage/quantity limits will be evaluated for medical necessity under Ohio Administrative Code 5160-101 and may be denied if criteria are not met.

InterQual ® CP: Molecular Diagnostics (see list in Coverage Rationale)
Ohio Administrative Code 5160-101

Note

Provider Action: Ordering and Documentation

Prior to ordering genetic testing, providers should ensure pre-test genetic counseling is offered and documented. Ordering providers must follow InterQual criteria and use clinical judgment; some tests (e.g., multi-gene panels for indications other than specified, RNA panels) are considered unproven and not medically necessary for most indications.

Pre-test genetic counseling strongly recommended and should be documented
Ordering provider should reference InterQual criteria and applicable state/contractual requirements

Services Determined Not Medically Necessary

RNA panel testing for hereditary cancers is explicitly listed as unproven and not medically necessary for all indications and therefore is not covered. Additionally, multi-gene hereditary cancer panels are not covered when used for indications other than individuals diagnosed with cancer at age 18 or younger.

Definitions and Test Types

Single gene / known familial mutation testing — definition and coverage

DefinitionTesting of an individual for a specific gene or for a known familial pathogenic variant (targeted single-gene or single-variant analysis)

Coverage stanceProven and medically necessary when indicated; single gene testing and known familial mutation testing for familial cancer is covered

Reference criteriaMedical necessity determined per InterQual CP: Molecular Diagnostics modules (e.g., BRCA1/BRCA2, Lynch syndrome, hereditary prostate cancer, PPGL)

RNA panel testing for hereditary cancers — definition and policy stance

DefinitionTesting that analyzes RNA (mRNA) — e.g., targeted or panel mRNA sequence analysis — as part of hereditary cancer evaluation

Policy stance

Background and Rationale

Hereditary cancer genetic testing is intended to identify germline variants that increase cancer risk. The policy distinguishes testing modalities: single-gene testing and testing for known familial mutations are considered proven and medically necessary when indicated, while multi-gene panels are subject to InterQual-based criteria and are only routinely covered in the pediatric cancer setting (diagnosis at age ≤18). The policy also notes that RNA (mRNA) panel testing for hereditary cancers is considered unproven and not medically necessary for all indications.