Genetic testing

Applies to:

Commercial group HMO, EPO, POS and PPO plans

MyPriority® individual HMO, POS and PPO plans

Medicare Advantage plans

Medicaid/Healthy Michigan Plan

Medical policy:

Genetics: Counseling, Testing and Screening - 91540

Definition:

Includes prenatal testing to detect changes in a fetus's genes or chromosomes before birth, newborn screening for genetic disorders, diagnostic testing to identify or rule out a specific genetic or chromosomal condition, carrier testing to identify people who carry one copy of a gene mutation.

Authorizations for genetic testing

Eight medically appropriate genetic testing categories appear in Sections C through J of our medical policy 91540, Genetics: Counseling, Testing and Screening (see above). These sections identify providers authorized to order the tests and give examples of indications for testing. Selected tests require prior authorization for participating providers; all codes require prior authorization for non-participating providers.

In some cases, genetic counseling is required before or after testing. Refer to Section V, Coding Information, of the policy for specific prior authorization requirements by CPT code.

Participating providers must request authorizations using our online Auth Request tool, which will direct your request to eviCore healthcare for review. In many cases, an authorization number can be provided immediately.

Non-participating providers must request authorizations using the general Medical prior authorization form if there's no service-specific form.