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Medical Policy

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 07/01/2024
Apolipoprotein E for Risk Assessment and Management of Cardiovascular Disease GT05 03/01/2024

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

GT42 03/01/2024
BRAF Genetic Testing To Select Melanoma or Glioma Patients for Targeted Therapy GT41 10/01/2023
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 06/01/2024

Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing

GT10 07/01/2024
Diagnostic Genetic Testing for α-Thalassemia GT52 04/01/2024
Diagnostic Genetic Testing for FMR1 and AFF2 Variants (including Fragile X and Fragile XE Syndromes) GT43 04/01/2024
Evaluating the Utility of Genetic Panels GT64 07/01/2024
Expanded Molecular Testing of Cancers to Select Targeted Therapies GT83 07/01/2024
Fetal RHD Genotyping using Maternal Plasma GT74 01/01/2024
Gene Expression Profiling for Melanoma GT29 08/01/2023
Gene Expression-Based Assays for Cancers of Unknown Primary GT15 05/01/2024
Gene-Based Tests for Screening, Detection, and Management of Prostate or Bladder Cancer GT17 07/01/2024
Genetic and Molecular Diagnostic Testing GT20 05/01/2024
Genetic Testing for Alpha-1 Antitrypsin Deficiency GT61 08/01/2023
Genetic Testing for Alzheimer's Disease GT01 01/01/2024
Genetic Testing for Biallelic RPE65 Variant-Associated Retinal Dystrophy GT21 06/01/2024
Genetic Testing for CADASIL Syndrome GT51 06/01/2024
Genetic Testing for Cutaneous Malignant Melanoma GT08 04/01/2024
Genetic Testing for Diagnosis and Management of Behavioral Health Conditions GT53 01/01/2024
Genetic Testing for Duchenne and Becker Muscular Dystrophy GT69 03/01/2024

Genetic Testing for Epilepsy

GT80 01/01/2024
Genetic Testing for Familial Hypercholesterolemia GT11 02/01/2024

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

GT02 05/01/2024
Genetic Testing for Heritable Disorders of Connective Tissue GT77 01/01/2024
Genetic Testing for Lactase Insufficiency GT67 03/01/2024
Genetic Testing for Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes GT06 01/01/2024
Genetic Testing for Macular Degeneration GT75 01/01/2024
Genetic Testing for Methionine Metabolism Enzymes, including MTHFR GT65 02/01/2024

Genetic Testing for Myeloid Neoplasms and Leukemia

GT59 06/01/2024
Genetic Testing for Neurofibromatosis Type 1 or 2 GT84 01/01/2024
Genetic Testing for Primary Mitochondrial Disorders GT54 01/01/2024
Genetic Testing for PTEN Hamartoma Tumor Syndrome GT63 08/01/2023

Genetic Testing for Rett Syndrome

GT68 01/01/2024
Genetic Testing for Statin-Induced Myopathy GT50 03/01/2024
Genetic Testing for the Diagnosis of Inherited Peripheral Neurophathies GT66 03/01/2024
Genetic Testing for the Evaluation of Products of Conception and Pregnancy Loss GT79 07/01/2024

Genotyping for 9p21 Single Nucleotide Variants to Predict Risk of Cardiovascular Disease or Aneurysm

GT62 07/01/2024

Identification of Microorganisms Using Nucleic Acid Probes

GT85 04/01/2024
IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia GT19 04/01/2024
Invasive Prenatal Fetal Diagnostic Testing Using Chromosomal Abnormalities GT78 07/01/2024
KRAS, NRAS, and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer GT13 07/01/2024
Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification GT70 03/01/2024
Molecular Testing for Interstitial Lung Disease GT55 02/01/2024

Noninvasive Prenatal Testing to Determine Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity

GT44 04/01/2024
Topographic Genotyping to Classify Cancer Risk GT16 07/01/2024
Preimplantation Genetic Testing of Embryos GT18 07/01/2024
Reproductive Carrier Screening for Genetic Diseases GT81 01/01/2024
Serologic Genetic and Molecular Screening for Colorectal Cancer GT86 07/01/2024
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 02/01/2024

Whole Exome and Whole Genome Sequencing

GT76 06/01/2024