Medical Necessity Guidelines: Genetic Testing ... - Tufts Health Plan

November 13, 2007: Criteria for coverage clarified in cases where members have 1 st degree relatives with known BRCA 1orBRCA2 mutation.January 30, 2008: Criteria for coverage of BRCA testing for females, not of Ashkenazi descent, changed: Personal of history ofprimary breast cancer changed from before age 40 to before age 50. Definitions of first and second degree relatives added toOverview.February 11, 2009: For consideration, BRCAPRO calculation must be submitted by the requesting provider which shows thatthe calculated risk of the Member having the mutation is greater than ten percentOctober 7, 2009 for an effective date of November 1, 2009: Coverage guidelines for BART testing added to the guideline.December 2009: limitations moved: placed within the body of the criteria.February 1, 2010: Reviewed by Medical Policy Advisory Group Committee (MPAGC), no content changes. Administrativeprocess changed.May 2011: Reviewed by MSPAC. BRCAPro risk clarified to read; “≥ (greater than or equal to).”January 1, 2012: New CPT codes addedApril 1, 2012: Coding update, HCPCS codes deleted by CMSMay 9, 2012: Added coverage of testing when the Member has a tumor which is triple negativeBACKGROUND, PRODUCT AND DISCLAIMER INFORMATIONMedical Necessity Guidelines are developed to determine coverage for Tufts Health Plan benefits, and are published to provide abetter understanding of the basis upon which coverage decisions are made. Tufts Health Plan makes coverage decisions usingthese guidelines, along with the Member’s benefit document, and in coordination with the Member’s physician(s) on a case-bycasebasis considering the individual Member's health care needs.Medical Necessity Guidelines are developed for selected therapeutic or diagnostic services found to be safe, but proven effectivein a limited, defined population of patients or clinical circumstances. They include concise clinical coverage criteria based oncurrent literature review, consultation with practicing physicians in the Tufts Health Plan service area who are medical experts inthe particular field, FDA and other government agency policies, and standards adopted by national accreditation organizations.Tufts Health Plan revises and updates Medical Necessity Guidelines annually, or more frequently if new evidence becomesavailable that suggests needed revisions.Medical Necessity Guidelines apply to all fully insured Tufts Health Plan products unless otherwise noted in this guideline or theMember’s benefit document. This guideline does not apply to Tufts Health Plan Medicare Preferred or to certain delegated servicearrangements. For self-insured plans, coverage may vary depending on the terms of the benefit document. If a discrepancy existsbetween a Medical Necessity Guideline and a self-insured Member’s benefit document, the provisions of the benefit documentwill govern. Applicable state or federal mandates will take precedence. Providers in the New Hampshire service area are subject toCigna’s provider agreements with respect to CareLink SM members.Treating providers are solely responsible for the medical advice and treatment of Members. The use of this guideline is not aguarantee of payment or a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to eligibility andbenefits on the date of service, coordination of benefits, referral/authorization, utilization management guidelines whenapplicable, and adherence to plan policies, plan procedures, and claims editing logic.Provider Services4 Medical Necessity Guidelines:Multi-site BRCA3, Single Site BRCA1 or BRCA2, & BART