Summary
Genetic testing is considered medically necessary to establish a molecular diagnosis of an inheritable disease when the member displays clinical features or is at direct risk of inheriting the mutation in question, the result of the test will directly impact the treatment being delivered to the member, and a definitive diagnosis remains uncertain after history, physical examination, and completion of conventional diagnostic studies. Section I lists inheritable diseases for which genetic testing is medically necessary when these criteria are met, and Section II lists specific tests, including BRCAnalysis, Breast Cancer Index, Cologuard, and Alzheimer's disease testing, that are medically necessary when their own criteria are met. Section III lists tests considered investigational for conditions such as arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C), Parkinson's disease, and migrainous vertigo. Section IV states that any genetic test not listed as medically necessary in Sections I or II is investigational, and that any home genetic test is investigational.
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