UHC – Genetic Testing for Hereditary Cancer (For Louisiana Only) Policy Number: Cs049la.L

Effective April 1, 2020:

Coverage Rationale

• Simplified content

Hereditary Breast and Ovarian Cancer (BRCA1/BRCA2)

• Revised list of proven and medically necessary indications for:
  • Men with a personal history of prostate cancer
  • Women with a personal history of Breast Cancer
  • Individuals without a personal history of a related cancer

Multi-Gene Hereditary Cancer Panel Testing Criteria

• Revised coverage guidelines/criteria for individuals:
  • With an indication for testing for hereditary Breast and Ovarian Cancer
  • With an indication for testing for hereditary colorectal
  • Without an indication for testing for hereditary Breast and Ovarian cancer or colorectal cancer
• Revised coverage criteria for genetic testing for BRCA1 and BRCA2 for individuals without a personal history of a related cancer; replaced criterion requiring “at least two Close Blood Relatives with a BRCA-Related Cancer” with “at least one Close Blood Relative with a BRCA-Related Cancer”

Definitions

• Added definition of:
  • BRCA-Related Cancers
  • Multi-Gene Panel
  •  Panel
• Modified definition of:
  • Lynch Syndrome-Associated Cancer

Applicable Codes

• Updated list of applicable CPT codes for multi-gene panel to reflect quarterly code edits:
  • Added 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, and 0138U
  • Removed 0104U

Supporting Information

• Updated Description of Services, Clinical Evidence, CMS, and References sections to reflect the most current information
• Archived previous policy version CS049LA.K  

Source: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/index/comm-plan/genetic-testing-hereditary-cancer-la-cs-04012020.pdf