Genetic Testing Policy
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Defines UHA's approach to determining medical necessity and payment for molecular and genetic diagnostic testing using independent review and prevailing payer guidance; applies to University Health Alliance (HSA) coverage determinations.
No material clinical or coverage changes in this revision.
Coverage Determination Rules
General coverage determination rules
Covered when ALL of the following are met:
Provider Responsibilities and Review Process
Use independent review and external guidance for medical necessity determinations
UHA will use an independent molecular diagnostic testing professional review organization and reference local authorities, NCCN, ASCO, and prevailing payer payment policies when making determinations of medical necessity and payment for molecular and genetic testing. The rationale for determinations will be included in all denials, and language from independent reviewers will be provided in most cases and upon request.
- Use an independent molecular diagnostic testing professional review organization as part of medical necessity and payment decisions.
- Reference local authorities, NCCN, ASCO, and prevailing payer payment policies in determinations.
- Include the rationale for determinations in all denial notices.
- Provide access to language from independent reviewers in most cases and upon request.
Key Definitions
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