Reviewed by Avalon 2nd Quarter 2024 CAB. Medical Director review 7/2024. Updated related policies, references, policy guidelines and recommendations. Added 3 Notes and renumbered all Notes 1-6. Under “when covered” section, several statements edited based on NCCN guidelines: close relatives are now first or second degree; exception in coverage statement #3. a. is now just for pancreatic cancer and does not include prostate cancer; only first-degree relatives of an individual affected with pancreatic cancer should be offered testing; clarified 5% probability cutoff; clarified testing for individuals of Ashkenazi Jewish ancestry. Under “when not covered” section, added new statement #3: “For all other purposes, including, but not limited to, testing of the general population, genetic testing for susceptibility to breast, ovarian, pancreatic, or prostate cancer is considered not medically necessary.” Added PLA codes 0474U and 0475U to Billing/Coding section. Notification 9/4/2024 for effective date 11/13/2024.

Reviewed with Avalon Q2 CAB 2024. Updated description, related policies, policy guidelines, and references. When covered #3 updated for clarification that screening in the reproductive partner is restricted to the genes for which their partner tested positive by carrier screening, not broad screening for themselves. When covered #5 updated for clarification that fetal testing must be a form of testing, not a form of screening (e.g., cfDNA screening), from an amnio or CVS sample. Added “Note 2: For 2 or more gene tests being run on the same platform, please refer to AHS - R2162 Reimbursement Policy” under when covered section. Added the following statement to when not covered: “Reimbursement is not allowed for the use of non-invasive prenatal screening (NIPS) to screen for single-gene mutations (i.e., autosomal recessive, autosomal dominant, X-linked) in the fetus." Added 0449U, 81479, 81599 to Billing/Coding section. Medical Director review 7/2024. Notification given 9/4/2024 for effective date 11/13/2024.