CommercialCoverageMedium impact
Genetic Testing for Heterozygous Familial Hypercholesterolemia (2.04.139)
Blue Shield of California·CA · Genetics, Cardiology, Internal Medicine +1 more·Genetic Testing
Effective date
Dec 1, 2025
We identified it
Nov 1, 2025
Summary
Blue Shield of California updated their genetic testing policy for familial hypercholesterolemia (FH), establishing specific criteria for when genetic testing is considered medically necessary versus investigational. The policy requires testing to be targeted to individuals with uncertain FH diagnosis and when needed for specialty medication eligibility.
Action Required
Before December 1, 2025: Billing team must review Blue Shield of California genetic testing claims for familial hypercholesterolemia to ensure documentation supports 'uncertain' diagnosis criteria (Dutch Lipid Clinic Network scores 3-8, or Simon-Broome probable FH criteria). Update prior authorization requests to include clinical scoring criteria and justification for specialty medication eligibility when applicable. Claims not meeting the specific policy criteria will be denied as investigational.