Genetic Testing for Diagnosis of Inherited Conditions - Medicare Advantage

This Humana Medicare Advantage coverage article outlines medical necessity criteria for genetic testing to diagnose inherited conditions. Coverage follows applicable NCDs/LCDs/LCAs; where CMS guidance is absent or incomplete, tests must have MolDX technical assessment OR FDA approval/clearance and meet clinical utility criteria (signs/symptoms, lack of definitive alternative tests, impact on management, and gene-disease validity). The policy provides condition-specific covered indications (with gene-, age-, and test-type limits), lists statutory exclusions (e.g., prenatal testing, screening without symptoms, investigational tests), and specifies documentation requirements (clinical findings, labs/imaging, specialist involvement, and evidence tests will affect management).

"For Celiac disease HLA testing: documentation of unclear diagnosis with ambiguous serology and/or inconsistent biopsy results."