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Blue Shield of CaliforniaAll Plans · Coverage · Genetic Testing · Genetics, Oncology, OB-GYNMedium impact

Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2) (2.04.02)

Effective date
Nov 1, 2026
Identified
Nov 1, 2025

Summary

Blue Shield of California's policy 2.04.02 states that genetic testing for BRCA1, BRCA2 and PALB2 variants may be considered medically necessary in cancer-affected individuals who meet the listed personal or family history criteria, such as breast cancer diagnosed at age 45 years or younger, personal history of epithelial ovarian carcinoma, or personal history of exocrine pancreatic cancer. BRCA1 and BRCA2 testing outside those criteria, PALB2 testing for individuals who do not meet the criteria, and testing in minors are considered investigational. This version is effective November 1, 2026, and the policy statement has no changes from the previous version.

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What to do

Action · 6 steps
01Effective November 1, 2026: Billing team, confirm that each BRCA1, BRCA2 or PALB2 test meets one of the criteria in the policy statement, since testing may be considered medically necessary only under those circumstances.
02BRCA1 and BRCA2 testing outside the criteria, PALB2 testing for individuals who do not meet the criteria, and genetic testing in minors are considered investigational.
03Attach the documentation the policy lists for clinical review: history and physical and/or consultation notes including ethnicity or ancestry; personal and family cancer history, including family relationships, sites and stages of cancer, age at diagnosis, and for breast cancer whether it is bilateral, premenopausal or triple negative; BRCA1, BRCA2 or PALB2 mutation history; genetic counseling results; and laboratory or pathology reports.
04For post-service claims, also include procedure reports and applicable test results.
05Genetic testing should be performed in a setting with suitably trained providers who can give pre- and post-test counseling and access to a Clinical Laboratory Improvement Amendments-licensed laboratory that offers comprehensive variant analysis.
06Direct questions about the policy's applicability to the Prior Authorization Department at (800) 541-6652.

Codes mentioned

81162811638116481165811668116781212812158121681217813078130881432

Original notice

Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2) (2.04.02)
blueshieldca.com · Always check the source before changing claims.
View original ↗

Related changes

See all Blue Shield of California changes →
Genetic Variant Testing (Including Liquid Biopsy) for Targeted Treatment in Advanced Cancer (2.04.151)MediumEffective Nov 1, 2026 · Genetic TestingGenetic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Advanced Cancer (2.04.151)MediumEffective Jun 1, 2026 · Genetic TestingGenetic Cancer Susceptibility Panels Using Next Generation Sequencing (2.04.93)HighEffective Apr 1, 2026 · Genetic TestingBrowse every Blue Shield of California change in the policy list

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