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Genetic Testing Section

Policy Name	Policy ID Number	Date Modified
Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening	GT12	10/01/2022
Apolipoprotein E for Risk Assessment and Management of Cardiovascular Disease	GT05	03/01/2023
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer	GT42	04/01/2023
BRAF Genetic Testing To Select Melanoma or Glioma Patients for Targeted Therapy	GT41	03/01/2023
Chromosomal Microarray Analysis (CMA) or Copy Number Analysis for the Genetic Evaluation of Patients with Developmental Delay, Intellectual Disability, Autism Spectrum Disorder, or Congenital Anomalies	GT58	08/01/2023
ClonoSEQ® Testing for the Assessment of Measurable Residual Disease (MRD)	GT88	04/01/2023
Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing	GT10	05/01/2023
Diagnostic Genetic Testing for α-Thalassemia	GT52	03/01/2023
Diagnostic Genetic Testing for FMR1 and AFF2 Variants (including Fragile X and Fragile XE Syndromes)	GT43	05/01/2023
Evaluating the Utility of Genetic Panels	GT64	09/01/2023
Expanded Molecular Testing of Cancers to Select Targeted Therapies	GT83	08/01/2023
Fetal RHD Genotyping using Maternal Plasma	GT74	09/01/2023
Gene Expression Profiling for Melanoma	GT29	08/01/2023
Gene Expression-Based Assays for Cancers of Unknown Primary	GT15	04/01/2023
Gene-Based Tests for Screening, Detection, and Management of Prostate or Bladder Cancer	GT17	07/01/2023
Genetic and Molecular Diagnostic Testing	GT20	06/01/2023
Genetic Testing for Alpha-1 Antitrypsin Deficiency	GT61	08/01/2023
Genetic Testing for Alzheimer's Disease	GT01	05/01/2023
Genetic Testing for Biallelic RPE65 Variant-Associated Retinal Dystrophy	GT21	04/01/2023
Genetic Testing for CADASIL Syndrome	GT51	07/01/2023
Genetic Testing for Cutaneous Malignant Melanoma	GT08	04/01/2023
Genetic Testing for Diagnosis and Management of Behavioral Health Conditions	GT53	07/01/2023
Genetic Testing for Duchenne and Becker Muscular Dystrophy	GT69	05/01/2023
Genetic Testing for Epilepsy	GT80	01/01/2023
Genetic Testing for Familial Hypercholesterolemia	GT11	02/01/2023
Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome	GT02	09/01/2023
Genetic Testing for Heritable Disorders of Connective Tissue	GT77	09/01/2023
Genetic Testing for Lactase Insufficiency	GT67	05/01/2023
Genetic Testing for Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes	GT06	01/01/2023
Genetic Testing for Macular Degeneration	GT75	09/01/2023
Genetic Testing for Methionine Metabolism Enzymes, including MTHFR	GT65	03/01/2023
Genetic Testing for Myeloid Neoplasms and Leukemia	GT59	06/01/2023
Genetic Testing for Neurofibromatosis Type 1 or 2	GT84	11/01/2022
Genetic Testing for Primary Mitochondrial Disorders	GT54	03/01/2022
Genetic Testing for PTEN Hamartoma Tumor Syndrome	GT63	08/01/2023
Genetic Testing for Rett Syndrome	GT68	11/01/2022
Genetic Testing for Statin-Induced Myopathy	GT50	03/01/2023
Genetic Testing for the Diagnosis of Inherited Peripheral Neurophathies	GT66	04/01/2023
Genetic Testing for the Evaluation of Products of Conception and Pregnancy Loss	GT79	07/01/2023
Genotyping for 9p21 Single Nucleotide Variants to Predict Risk of Cardiovascular Disease or Aneurysm Policy Version Effective 8/1/2023: Genotyping for 9p21 Single Nucleotide Variants to Predict Risk of Cardiovascular Disease or Aneurysm	GT62	07/01/2023
Identification of Microorganisms Using Nucleic Acid Probes Policy Version Effective 11/1/2023: Identification of Microorganisms Using Nucleic Acid Probes	GT85	08/01/2023
IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia	GT19	05/01/2023
Invasive Prenatal Fetal Diagnostic Testing Using Chromosomal Abnormalities	GT78	07/01/2023
KRAS, NRAS, and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer	GT13	03/01/2023
Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification	GT70	03/01/2023
Molecular Testing for Interstitial Lung Disease	GT55	02/01/2023
Noninvasive Prenatal Testing to Determine Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity	GT44	05/01/2023
Topographic Genotyping to Classify Cancer Risk	GT16	07/01/2023
Preimplantation Genetic Testing of Embryos	GT18	07/01/2023
Reproductive Carrier Screening for Genetic Diseases	GT81	07/01/2023
Serologic Genetic and Molecular Screening for Colorectal Cancer	GT86	08/01/2023
Single-nucleotide Variants (SNVs) to Predict Risk of NonFamilial Breast Cancer	GT23	08/01/2023
Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC)	GT56	04/01/2023
Whole Exome and Whole Genome Sequencing	GT76	09/01/2023


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