Under Cigna-administered plans, prior to undergoing certain genetic tests, customers are required to get counseling from an independent genetics professional on our list of participating genetic counselors in order for precertification to be approved.
The program is designed to protect your patients and our customers:
- Genetic counseling provides individuals with the opportunity to become fully informed about complex genetic tests and make an informed decision about testing.
- Meeting with an independent genetics professional who is not employed by any clinical or genetic laboratory prevents conflict of interest between the counselor and the facility that performs the tests.
- Medical necessity review and prior authorization helps ensure that individuals receive quality and cost-effective care that is covered under their benefit plans.
Who It's For
The Genetic Testing and Counseling Program includes a precertification requirement and medical necessity review for certain Tier 1 and all Tier 2 genetic testing codes, including those outlined below, that require genetic counseling. To determine if your patient’s plan requires precertification, please look for "Outpatient Procedures" listed on their Cigna ID card.
For a complete, up-to-date list of services that require precertification of coverage, health care providers can log in to Cigna for Health Care Professionals and click on "Precertification Policies" under "Useful Link copy." Once there, please see the "Master Precertification Policy" document.
81201, 81202, 81203, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81403, 81406, 81435, and 81436
81280, 81281, 81282, 81403, 81404, 81405, 81406, 81407, 81408, 81413, 81414, 81439, S3861, S3865, and S3866
81162, 81201, 81202, 81203, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81321, 81322, 81323, 81401, 81403, 81404, 81406, 81432, 81433, 81435, 81436, 81437, 81438, S3840, S3841, and S3842
How It Works
- Refer the patient
Review Cigna's list of participating genetic counselors and refer the patient to an independent board-certified genetic counselor or clinical geneticist.
- Submit the request
The genetic counselor or clinical geneticist typically submits the request, including:
- A completed genetic testing recommendation form
- A three-generation pedigree
- A copy of the ordering health care provider’s laboratory requisition form
- A copy of your genetics evaluation documentation
- Cigna review and decision
We review the precertification request. We understand that many tests, especially the BRCA test, may be urgent. If the precertification request is approved, we will inform the ordering physician. If the precertification request is denied, standard appeal rights will be offered.
- Genetic testing and follow-up
The genetics professional can facilitate the blood or specimen collection, genetic testing, and result interpretation. The genetics professional will refer the patient back to the ordering physician for ongoing management, providing them with a consultation report.