Lessons Learned: What You Need to Know About Obtaining Authorization for Genetic Testing

If you have ever ordered genetic testing (and most of us have!) chances are you have received a denial from an insurance company. Confused? Frustrated? Not sure what the next steps are? OAGC members Sarah Brunner and Katlin Peck are here to help!

Sarah Brunner, MS, CGC
Sarah Brunner, MS, CGC

Sarah is a genetic counselor at Paramount Health Care, an Affiliate of the ProMedica Health System. At Paramount Health Care, Sarah works in several areas including prior authorizations, provider appeals, and medical policy development. She graduated from the University of Cincinnati Genetic Counseling Program in 2015 and currently lives in Perrysburg with her husband and daughter.

Katlin Peck, MS, CGC
Katlin Peck, MS, CGC

Katlin is a genetic counselor at eviCore Healthcare, where she specializes in Government Business utilization management, including prior authorization and claims processing related topics. She graduated from the University of Cincinnati Genetic Counseling Program in 2015 and is currently pursuing her MBA through the University of Hartford. She lives in Dayton with her husband and daughter.

We’ve all been there. You’ve submitted a prior authorization request for genetic testing and you’ve received that frustrating denial letter. Before you start the appeal process or request a peer to peer discussion, it is important to understand why the denial occurred. We are genetic counselors with clinical experience who are now working in the utilization management world of health insurance. Here are a few tips that may help save you time – and help reach approval for patients who are eligible for genetic tests.

Learn why the denial occurred

  • In the denial letter you receive, there should be a section that outlines why the test/CPT code was denied. If the denial occurred related to medical necessity, the reason can be used to address any issues when going through the appeal process or peer to peer. For example, if the letter says your patient needs 3 findings related to condition X in order for the testing to be approved, have this information outlined in the written appeal or ready to go for a peer to peer.
  • Sometimes denials occur completely unrelated to medical necessity, such as with a policy exclusion. For example, with an employer-funded health plan, the employer could elect to exclude coverage for genetic testing (with the exception of tests required by the ACA) to be covered with non-grandfathered plans. In this circumstance, as frustrating as it may be, genetic testing would not be a covered benefit (regardless of medical necessity). Self-pay options or grants may be an option to pursue in these circumstances.
  • Denials may also occur due to limited evidence regarding clinical utility for a test. In this case, a plan may designate a specific test as “investigational and experimental,” and would elect to not cover a test.

Access available policy information

  • Many insurance companies post their medical policies online. If you look over the relevant policy before you submit a request, it may save you time in the long run. Within these guidelines, there may be coding guidance, exclusions or medical necessity criteria. If you are familiar with what the health plan is looking for to provide approval, you can better prepare that information for them.

Provide concise and clear documentation

  • Make sure the records you send in are for the correct patient. We see a high percentage of non-matching patient information or only general information not specific to a patient sent with testing requests. 
  • Make sure your notes are detailed and specifically outline why the test is needed and what you discussed with the patient. Don’t assume the reviewer can read your mind or read between the lines of your notes. Make it clear what was discussed and why the test is necessary.
  • Confirm the records clearly state what test is being ordered, where the test will be performed, and what CPT codes are being billed.
  • In the case of panels, it is also helpful to note which genes are being billed with which CPT codes. There is nothing more frustrating for a reviewer than having to search through 100+ pages of records to identify what test is being ordered.
  • Understand what CPT codes you are submitting. Coding can be very confusing! With genetic testing, there can be multiple “correct” ways to code one test. For example, a single CPT code could be used for a multi-gene panel, or a laboratory may submit “stacked” CPT codes to represent individual genes in the test. However, a specific health plan may have a preference on how it is coded that can make the difference between an approval or a denial. The servicing laboratory should also be able to provide you with information on how they plan to bill the requested testing. Here are some resources for genetic counselors to help navigate coding:
  • Make sure to read the description of the CPT code you are requesting and make sure it is representative of the test being performed. For example, if you are ordering a sequencing test, you will want to make sure you are choosing the sequence code and not the deletion/duplication code (if applicable).

By considering the above when ordering genetic testing you may find the number of denials you receive decreasing. However, it is important to note this list is not exhaustive and if you have specific questions, we encourage you to reach out to the health plan directly.

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