Genetic Testing (CPB 0140, reviewed 2026-06-01)
Summary
Aetna considers genetic testing medically necessary to establish a molecular diagnosis of an inheritable disease when the member has clinical features or is at direct risk of inheriting the mutation, the result will directly impact the treatment being delivered, and a definitive diagnosis remains uncertain after history, physical examination, pedigree analysis, genetic counseling and conventional diagnostic studies. Germline genetic testing for familial colorectal, endometrial or gastric cancer is covered when the NCCN testing criteria for the individual syndrome are met, and multi-gene panels for inherited cancers are covered only for individuals with a personal or family history of a related cancer when more than one inherited cancer syndrome could be responsible. Prenatal and preconception carrier screening is covered when the results will be used in management of the pregnancy, a potentially affected fetus, or family planning. Whole exome or whole genome sequencing is covered for an unexplained congenital or neurodevelopmental disorder only when all of the stated criteria are met. Polygenic risk scores, panel tests that include RNA analysis, and genetic testing for indications not listed in the policy are considered experimental, investigational, or unproven.
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