All PlansCoverageHigh impact
Pharmacogenetic and Pharmacodynamic Testing (CPB 0715, reviewed 2025-12-03)
Aetna·Oncology, Hematology, Genetics +4 more·Medical Policy
Effective date
Dec 3, 2025
We identified it
Aug 13, 2026
Summary
Aetna updated its pharmacogenetic and pharmacodynamic testing policy (CPB 0715) to define medical necessity for specific genetic tests tied to targeted cancer therapies and other precision medicine treatments. The policy explicitly identifies which testing panels are medically necessary (e.g., ALK fusion testing for crizotinib) and which are NOT (e.g., FoundationOne CDx for ALK-positive NSCLC). Billing teams must verify test medical necessity against this policy before processing claims to avoid denials.
Action Required
Effective immediately (policy dated 2025-12-03): Billing team must implement pre-claim verification for all pharmacogenetic and pharmacodynamic testing requests. (1) Update billing system to flag tests listed in CPB 0715 for manual review prior to claim submission. (2) Cross-reference all genetic testing requests against the policy's 'medically necessary' and 'not medically necessary' lists before processing. (3) Deny or hold claims for non-covered tests (e.g., FoundationOne CDx/Liquid CDx for ALK-positive NSCLC, EGFR NSCLC, melanoma, or ovarian cancer indications; Guardant360CDx for NSCLC; oncoReveal Dx for NSCLC) and communicate specific denial reasons to providers referencing CPB 0715. (4) Ensure providers are educated on approved alternative tests (e.g., targeted ALK mutation testing instead of FoundationOne panels). (5) Update prior authorization templates and clinical criteria in the billing system to align with this policy. Failure to enforce these restrictions will result in claim denials and potential overpayment recovery.