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Medical Policy

Genetic Testing Section

Policy Name Date Modified
Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening 10/01/2018
Apolipoprotein E for Risk Assessment and Management of Cardiovascular Disease 02/01/2018
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer 01/01/2019
BRAF Genetic Testing To Select Melanoma or Glioma Patients for Targeted Therapy 10/01/2018
Chromosomal Microarray Analysis (CMA) for the Genetic Evaluation of Patients with Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, or Congenital Anomalies 01/01/2019
Chromosomal Microarray (CMA) Testing for the Evaluation of Products of Conception and Pregnancy Loss 11/01/2018

Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing

12/01/2018
DNA-Based Testing for Adolescent Idiopathic Scoliosis 02/01/2018
Evaluating the Utility of Genetic Panels 01/01/2019
Fetal RHD Genotyping using Maternal Plasma 08/01/2018
Gene Expression Profiling for Melanoma 01/01/2019
Gene Expression Testing to Predict Coronary Artery Disease 02/01/2018
Gene Expression-Based Assays for Cancers of Unknown Primary 04/02/2018
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer 01/01/2019
Genetic and Molecular Diagnostic Testing 01/01/2019
Genetic Testing for α-Thalassemia 11/01/2018
Genetic Testing for Alpha-1 Antitrypsin Deficiency 07/01/2018
Genetic Testing for Alzheimer's Disease 11/01/2018
Genetic Testing for Biallelic RPE65 Variant-Associated Retinal Dystrophy 03/01/2018
Genetic Testing for CADASIL Syndrome 06/01/2018
Genetic Testing for Cardiac Ion Channelopathies 02/01/2018
Genetic Testing for Cutaneous Malignant Melanoma 03/01/2018
Genetic Testing for Diagnosis and Management of Behavioral Health Conditions 12/01/2018
Genetic Testing for Duchenne and Becker Muscular Dystrophy 11/01/2018
Genetic Testing for Epilepsy 01/01/2019
Genetic Testing for Familial Hypercholesterolemia 01/01/2018
Genetic Testing for FMR1 and AFF2 Variants (including Fragile X and Fragile XE Syndromes) 01/01/2019

Genetic Testing for Hereditary Breast and/or Ovarian Cancer and Li-Fraumeni Syndrome

01/01/2019
Genetic Testing for Hereditary Hemochromatosis 02/01/2018
Genetic Testing for Heritable Disorders of Connective Tissue 07/01/2018
Genetic Testing for Inherited Susceptibility to Colon Cancer 01/01/2019
Genetic Testing for Inherited Thrombophilia 04/01/2018
Genetic Testing for Lactase Insufficiency 03/01/2018
Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment 06/01/2018
Genetic Testing for Macular Degeneration 08/01/2018
Genetic Testing for Methionine Metabolism Enzymes, including MTHFR, for Indications Other than Thrombophilia 12/01/2018

Genetic Testing for Myeloid Neoplasms and Leukemia

11/01/2018
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy 04/01/2018
Genetic Testing for PTEN Hamartoma Tumor Syndrome 11/01/2018

Genetic Testing for Rett Syndrome

12/01/2018
Genetic Testing for Statin-Induced Myopathy 02/01/2018
Genetic Testing for the Diagnosis of Inherited Peripheral Neurophathies 01/01/2019
Genotyping for 9p21 Single Nucleotide Polymorphisms to Predict Risk of Cardiovascular Disease or Aneurysm 07/01/2018
IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia 02/01/2018
Invasive Prenatal Fetal Diagnostic Testing Using Chromosomal Microarray Analysis (CMA) 11/01/2018
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy 12/01/2018
KRAS, NRAS, and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer 10/01/2018
Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification 02/01/2018
Molecular Markers in Fine Needle Aspirates of the Thyroid 11/01/2018
Molecular Analysis for Targeted Therapy of Non-Small Cell Lung Cancer (NSCLC) 01/01/2019
Multigene Expression Assay for Predicting Recurrence in Colon Cancer 12/01/2018
PathFinderTG® Molecular Testing 06/01/2018
Preimplantation Genetic Testing 11/01/2018
Reproductive Carrier Screening for Genetic Diseases 01/01/2019

Sequencing-based Tests to Determine Fetal Aneuploidies and Microdeletions from Maternal Plasma DNA

11/01/2018
Single-nucleotide Variants (SNVs) to Predict Risk of NonFamilial Breast Cancer 01/01/2019

Whole Exome and Whole Genome Sequencing

12/01/2018