Prevea360 Health Plan maintains and updates these genetic testing medical policies.
The chart below identifies medical policy components, which may vary by test. See individual policy for details:
Medical policy number | Medical policy | Policy type | Authorization required | Genetic counseling required | Medical necessity criteria |
MP9012 | General genetic testing policy | General | Some | X | |
MP9472 | Hereditary Cardiac Disease & Arrhythmias | Cardiac | X | X | X |
MP9473 | Thrombophilia | General | X | ||
MP9477 | Reproductive Carrier Screening & Prenatal Diagnosis | Maternal-fetal | Some | X | |
MP9478 | High-penetrance breast and/or epithelial ovarian cancer susceptibility | Cancer | X | X | X |
MP9479 | Pharmacogenetic testing | General | X | X | |
MP9482 | Polyposis | Cancer | X | X | X |
MP9483 | Multiple Endocrine Neoplasia, Type 1 & 2 | Cancer | X | X | X |
MP9484 | Diffuse Gastric Cancer – CDH1 Gene | Cancer | X | X | X |
MP9486 | Somatic Tumor Markers | General | X | ||
MP9487 | Lynch Syndrome | Cancer | X | X | X |
MP9488 | Cowden Syndrome – PTEN Gene | Cancer | X | X | X |
MP9491 | Chromosomal Microarray Analysis | General | X | ||
MP9497 | Neurologic Disorders | General | X | X | X |
MP9504 | Stickler Syndrome | General | X | X | X |
MP9505 | Ehlers-Danlos Syndrome | General | X | X | X |
MP9506 | Marfan Syndrome | General | X | X | X |
MP9507 | Maturity Onset of the Young Sequencing Panel | General | X | X | |
MP9521 | Hereditary Cancer Susceptibility | Cancer | X | ||
MP9524 | Hereditary Hemorrhagic Telangiectasia (HHT) | General | X | X | X |
MP9525 | Familial Hypercholesterolemia | General | X | X | X |
MP9527 | Birt Hogg Dube Syndrome | General | X | X | X |
MP9534 | Focal Segmental Glomerular Sclerosis | General | X | X | X |
MP9548 | Whole Exome and Whole Genome Sequencing | General | X | X | X |
Covered genetic testing that does not require a 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
Certain tests require pre-test and post- test genetic counseling. Prior authorization is not required for referrals to a genetic counselor.
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.