IHCP announces a general coverage policy for #genetic testing services

Effective January 1, 2015, the Indiana Health Coverage Programs (IHCP) will implement a new general policy regarding coverage of genetic testing services. This policy will address IHCP’s coverage of genetic testing services overall.

Coverage policies issued regarding specific genetic tests or techniques will supplement this policy.

The National Human Genome Research Institute defines genetic testing as follows:

The term “genetic testing” covers an array of techniques including

analysis of human DNA, RNA or protein. Genetic tests are used as a

healthcare tool to detect gene variants associated with a specific

disease or condition, as well as for non-clinical uses such as paternity

testing and forensics. In the clinical setting, genetic tests can be

performed to confirm a suspected diagnosis, to predict the possibility

of future illness, to detect the presence of a carrier state in unaffected

individuals (whose children may be at risk), and to predict response to

therapy. They are also performed to screen fetuses, newborns or

embryos used in in-vitro fertilization for genetic defects.

Coverage requirements

The IHCP provides coverage for a variety of genetic tests when provided in compliance with IHCP coverage and billing guidelines. The following circumstances apply for any genetic testing service to be covered:

 The genetic disorder must be associated with a potentially significant disability; and

 The risk of the significant disability from the genetic disorder cannot be identified through biochemical or other testing

(for example, ultrasound screening for aortic disease in Marfan’s syndrome); and

 A specific mutation, or set of mutations, has been established in scientific literature to be reliably associated with the disease; and

 The results of the genetic test could impact the medical management of the individual with improved net-health outcomes; and

 No determinable diagnosis can be gathered from the history, physical examination, pedigree analysis, genetic counseling, and completion of conventional diagnostic studies

 Prior authorization is obtained, if required

Under the following circumstances, genetic testing services are not covered:

 Testing for the sole convenience of information for the patient without

impacting treatment

 All screening tests, except those listed under the State’s required Newborn

Screening

 Tests performed for the medical management of other family members

unless otherwise specified in policy

 History, physical examination, pedigree analysis, genetic counseling, or

completion of conventional diagnostic studies has given a definitive

diagnosis

 The genetic test was previously performed for the member to provide a

conclusive diagnosis of the same genetic disorder

 Testing to establish paternity