Genetic testing

Prevea360 Health Plan maintains and updates these genetic testing medical policies.

  • Current Medical Policy MP9012 will serve as the general policy for genetic testing and will provide links to specific genetic tests.
  • If a medical policy does not refer to a specific genetic test, applicable evidenced based guidelines and a prior authorization will be required.
  • Authorization, Genetic Counseling and Medical Necessity requirements may be test specific, as identified within each medical policy.
  • Medical necessity criteria will be applied to HMO, POS, PPO, and ASO members.

The chart below identifies medical policy components, which may vary by test. See individual policy for details:

Medical policy numberMedical policyPolicy typeAuthorization requiredGenetic counseling requiredMedical necessity criteria
MP9012General genetic testing policyGeneralSome
MP9472Hereditary Cardiac Disease & ArrhythmiasCardiacXXX

MP9477Reproductive Carrier Screening & Prenatal DiagnosisMaternal-fetalSome
MP9478High-penetrance breast and/or epithelial ovarian cancer susceptibilityCancerXXX
MP9479 Pharmacogenetic testingGeneralX
MP9483Multiple Endocrine Neoplasia, Type 1 & 2CancerXXX
MP9484Diffuse Gastric Cancer – CDH1 GeneCancerXXX
MP9486Somatic Tumor MarkersGeneral

MP9487Lynch SyndromeCancerXXX
MP9488Cowden Syndrome – PTEN GeneCancerXXX
MP9491Chromosomal Microarray AnalysisGeneral

MP9497Neurologic DisordersGeneralXXX
MP9504Stickler SyndromeGeneralXXX
MP9505Ehlers-Danlos SyndromeGeneralXXX
MP9506Marfan SyndromeGeneralXXX
MP9507Maturity Onset of the Young Sequencing PanelGeneralXX
MP9521Hereditary Cancer SusceptibilityCancer

MP9524Hereditary Hemorrhagic Telangiectasia (HHT)GeneralXXX
MP9525Familial HypercholesterolemiaGeneralXXX
MP9527Birt Hogg Dube SyndromeGeneralXXX
MP9534Focal Segmental Glomerular SclerosisGeneralXXX
MP9548Whole Exome and Whole Genome SequencingGeneralXXX

Covered genetic testing that does not require a prior authorization

Genetic testing - prior authorization

If you are a Prevea360 Health Plan Provider Portal user, submit prior authorization requests via the provider portal

If you do not have access to submit prior authorization via the provider portal, please fax the Genetic Testing prior authorization form to the number indicated on the form

Genetic counseling requirement

Certain tests require pre-test and post- test genetic counseling. Prior authorization is not required for referrals to a genetic counselor.

Genetic Counseling Resources

St. Vincent Genetic Counseling department can provide genetic counseling for Prevea360 Health Plan members.

Members can be referred to St. Vincent Genetic Counseling at 920-433-8559 (fax 920-431-3138). Additionally, if there are in-network providers who employ genetic counselors may continue to use a current process that may be in place to comply with Prevea360 Health Plan’s updated genetics testing medical policies where genetic counseling is required.

Prevea360 Health Plan recognizes the limited accessibility of genetic counselors. We've partnered with InformedDNA (IDNA) to provide telephonic genetic counseling services for Prevea360 Health Plan members. The goal is to improve member satisfaction and ease the burden for our providers. 

If no genetic counselors are available within your organization or there is an access issue, Prevea360 Health Plan’s member may be referred to InformedDNA (IDNA). Use the IDNA Cancer Genetic Counseling Referral form or the Cardiac Genetic Counseling Referral form to refer to IDNA.