Genetic Testing for Hereditary Cancer (for Nebraska Only)
Policy governing coverage of hereditary cancer genetic testing for members in Nebraska, including single-gene, BRCA1/2, and multi-gene panel testing and related criteria.
Coverage rationale: replaced 'Primary Solid Tumor Cancer(s)' with 'Primary Solid Tumor(s)' and updated criteria language for individuals with a personal history of a primary solid tumor, including adding malignant phyllodes tumors as a qualifying personal history.
Updated numerous specific eligibility criteria wording (e.g., sex assigned at birth phrasing, expanded list of tumor types to 'neuroendocrine tumor', and expanded list of tumor-detected variants with examples of genes that have clinical implications if detected in the germline).
Revised coverage criteria for individuals with no personal history of a primary solid tumor: added relatives with triple-negative breast cancer and relatives who were assigned male at birth with breast cancer as qualifying family history criteria; replaced some relative tumor-type criteria with broader 'neuroendocrine tumor' and clarified ovarian cancer phrasing.
Added criterion requiring at least one first- or second-degree relative with a history of Triple-Negative Breast Cancer for testing eligibility.
Added criterion requiring at least one first- or second-degree relative with a history of Breast Cancer where the relative was assigned male at birth.
Replaced criterion referencing a first-degree relative with paraganglioma or pheochromocytoma with a broader first-degree relative history of neuroendocrine tumor (e.g., adrenocortical carcinoma, paraganglioma, or pheochromocytoma).
Replaced wording about first- or second-degree relative history of ovarian, fallopian tube, and/or primary peritoneal cancer (text truncated in excerpt).
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.
Removed CPT codes 81433, 81436, and 81438 from applicable codes.
Revised descriptions for CPT codes 81432, 81435, and 81437.
Updated Description of Services, Clinical Evidence, FDA, and References sections to reflect current information.
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