Mountain State Medical Policy Bulletin
Section: Laboratory
Number: L-34
Topic: Genetic Testing
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 07/2005

General Policy Guidelines

Indications and Limitations of Coverage

Genetic testing performed to diagnose patients with signs and symptoms of possible genetic disease is generally covered.  In addition, the test results must have a direct effect on the patient's treatment.

Genetic testing performed on patients with no current evidence or manifestation of genetic disease (i.e., asymptomatic) is considered genetic screening and is noncovered except for those groups/programs that specifically identify coverage in benefits. This includes genetic testing performed to determine susceptibility or predisposition to diseases such as cancer and heart disease and genetic testing for carrier identification to determine if a person is a "carrier" of an abnormal gene.

The following testing is covered for symptomatic patients. The testing is also covered for asymptomatic patients when the patient's contract covers genetic screening. This is not an all-inclusive list.

  • Inherited BRCA-1 or BRCA-2 mutations for breast and ovarian cancer (S3818, S3819, S3820, S3822, S3823)
  • Germline mutations of the RET proto-oncogene in medullary carcinoma of the thyroid
  • Inherited susceptibility to colon cancer (S3828, S3829, S3830, S3831, S3833, S3834)
  • Cystic fibrosis (S3835)
  • Hemochromatosis (S3837)
  • Retinoblastoma (S3841)
  • Von Hippel-Lindau disease (S3842)
  • Alpha-thalassemia (S3845)
  • E beta thalassemia (S3846)
  • Tay-Sachs disease (S3847)
  • Gaucher disease (S3848)
  • Niemann-Pic diseases (S3849)
  • Sickle cell anemia (S3850)
  • Canavan disease (S3851)
  • Multiple endocrine neoplasia type 2 (S3840)
  • Factor V Leiden thrombophilia (S3843)
  • Congenital profound deafness (S3844)
  • Myotonic muscular dystrophy (S3853) 

Genetic testing for diagnosis or risk assessment of Alzheimer's disease (S3852) is considered experimental/investigational and therefore, not covered and not eligible for payment. This includes, but is not limited to, testing for the apolipoprotein E epsilon 4 allele, presenilin genes, or amyloid precursor gene. There is no evidence that testing for genetic mutations improves the sensitivity or specificity of clinical criteria and would not alter diagnostic testing for other causes of dementia. A participating, preferred, or network provider can bill the member for the denied service.

Date Last Reviewed: 08/2004

Genetic testing is a complex process. The results depend on reliable laboratory procedures and accurate interpretation of results. When no code exists, molecular diagnostic testing (codes 83890-83906) and cytogenetic testing (codes 88230-88289) may be reported for genetic testing. Different combinations of the codes may be reported depending on the clinical circumstances. In some cases, certain codes may be reported multiple times.

Genetic counseling (S0265) is generally provided in conjunction with genetic testing. Counseling usually occurs when the results of the tests are provided to the patient and intervention strategies are discussed.  Coverage for genetic counseling is determined according to individual or group customer benefits. When genetic testing is noncovered, the counseling performed in conjunction with the testing is also noncovered.

NOTE:
See Medical Policy Bulletins U-4 and U-6 for information on prenatal genetic testing.

Description

Genetic diseases are conditions resulting in abnormalities of DNA. Some genetic diseases are transmitted from parents to their children, and in other circumstances, genetic diseases may occur spontaneously, as in mutations.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

838908389183892838938389483896
838978389883901839028390383904
839058390688230882338823588237
882398824088241882458824888249
882618826288263882648826788269
882718827288273882748827588280
882838828588289S0265S3818S3819
S3820S3822S3823S3828S3829S3830
S3831S3833S3834S3835S3837S3840
S3841S3842S3843S3844S3845S3846
S3847S3848S3849S3850S3851S3852
S3853     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

12/1999, Blue Shield explains genetic testing coverage

References

National Blue Cross Blue Shield Association Medical Policy 2.04.02, Genetic Testing for Inherited BRCA1 or BRCA2 Mutations, 03/2002

National Blue Cross Blue Shield Association Medical Policy 2.04.05, Genetic Testing for Germline Mutations of the RET Proto-Oncogene in Medullary Carcinoma of the Thyroid, 11/1998

National Blue Cross Blue Shield Association Medical Policy 2.04.08, Genetic Testing for Inherited Susceptibility to Colon Cancer Including Microsatellite Instability, 03/2002

National Blue Cross Blue Shield Association Medical Policy 2.04.13, Genetic Testing for Familial Alzheimer's Disease, 10/2000

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Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.