No coverage for testing based on family history alone, except for testing for the breast cancer susceptibility gene (BRCA). Genetic testing is covered to establish a molecular diagnosis of an inheritable disease when all of the following criteria are met:
- The member displays clinical features, or is at direct risk of inheriting the mutation in question (pre-symptomatic);
- The result of the test will directly impact the treatment being delivered to the member;
- The testing method is considered scientifically valid for identification of a genetically-linked inheritable disease; and
- After history, physical examination, pedigree analysis, genetic counseling and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain.
Preauthorization by medical plan is required.