Genetic Testing for Hereditary and Multifactorial Conditions - (0052)

Genetic testing is covered only when tests are FDA‑approved and/or performed in a CLIA‑accredited lab, are medically necessary for the listed indication, and will directly impact clinical decision‑making—single‑gene testing is allowed for symptomatic individuals or those with documented direct risk, while multigene panels, gene‑expression classifiers and polygenic risk scores are covered only under strict, outcome‑proven clinical criteria. The policy excludes and will not reimburse specific tests/codes (e.g., APOE S3852, APOL1 0355U, MTHFR 81291, Corus and other listed assays and CPT/HCPCS codes 81291, 81490, 0004M, 0156U, 0170U, 0355U, 0389U, 0398U, 0401U, 0439U, 0440U, HCPCS S3852) and requires documentation of FDA/CLIA status, medical necessity, expected management impact, relevant phenotype/family history, and guideline concordance.

"Laboratory testing, including genetic testing (proprietary or non-proprietary, individual test or panel) is considered medically necessary when ALL of the following criteria are met: - The proposed..."