- Precertification requirements
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. This will help ensure that individuals receive high quality and cost-effective care that is covered under their benefit plans.
Genetic tests historically included in program Related CPT/HCPCS codes Breast and ovarian cancer (BRCA) 81162, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81432, and 81433 Colorectal cancer 81201, 81202, 81203, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81403, 81406, 81435, and 81436 Long-QT 81280, 81281, 81282, and 81406 Genetic tests included in program as of July 15, 2016 Related CPT/HCPCS codes Exome test 81415, 81416 Hereditary arrhythmias and cardiomyopathies (all hereditary cardiac tests) 81403, 81404, 81405, 81406, 81407, 81408, S3861, S3865, and S3866 Pediatric microarray test (excluding prenatal testing) 81228, 81229, and S3870 Hereditary cancer syndromes (all hereditary cancer tests) 81321, 81322, 81323, 81401, 81403, 81404, 81405, 81406, S3840, S3841, and S3842
- Genetic counseling requirement
Genetic counseling provides individuals with the opportunity to become fully informed about complex genetic tests. Therefore, as part of the precertification requirements for this program, individuals with Cigna-administered coverage are required to receive pre-testing genetic counseling from an independent board-certified genetic counselor, clinical geneticist or other health care professional who is approved by Cigna to provide Genetic Counseling for this program in order for precertification to be approved.
We have historically required genetic counseling for three hereditary conditions – BRCA, colorectal cancer syndromes, and Long QT syndrome – in order for precertification to be approved.
Beginning on July 15, 2016, we will expand the scope of our Genetic Testing and Counseling Program to require genetic counseling for additional tests and indications, including:
• Whole exome sequencing (WES)
• Other hereditary cardiomyopathies and arrhythmias, including dilated cardiomyopathy (DCM) and other known familial mutations in addition to Long-QT syndrome.
• Comparative genomic hybridization (CGH) and chromosomal microarray analysis (CMA) for children 13 years of age or younger with an autism spectrum disorder without phenotypic characteristics, developmental delay, or intellectual disability in which the clear signs of a genetic disorder are missing, and for multiple congenital anomalies not specific to a well-defined genetic disorder. Please note that CGH and CMA testing for reproductive or prenatal indications will not require genetic counseling in order for precertification to be approved.
• Hereditary cancer susceptibility and risk testing other than for hereditary breast and ovarian cancer and hereditary colorectal cancer syndrome.
Prior to requesting precertification for these conditions, ordering physicians should refer their patients with Cigna-administered coverage (and whose benefit plan requires precertification for outpatient procedures) to a participating independent board-certified genetic counselor or clinical geneticist for genetic counseling. This genetics professional’s role will not only be to provide pre- and post-testing genetic counseling for individuals, but also to provide support to the ordering physician and help facilitate the overall testing process.
- What does an "independent board-certified genetic counselor" mean?
An independent genetics professional is one who is not employed by any clinical or genetic laboratory. Requiring that individuals receive services from an independent genetics professional ensures that there is no conflict of interest between the genetics professional and the facility that performs the tests.
For more information about how to find a genetic counselor, please review the information in the "Find a participating independent board-certified genetic counselor or clinical geneticist" section below.
- Find a participating independent board-certified genetic counselor or clinical geneticist
Health care professionals and their patients can find a participating independent board-certified genetic counselor or clinical geneticist four different ways:
- By reviewing our list of participating genetic counselors.
- By calling InformedDNA at 1.800.975.4819 for access to nationwide in-network telephone genetic counseling. Health care professionals can also visit their website at www.informedDNA.com to submit a referral or for more information.
- By calling us at 1. 800.88.Cigna (882.4462) or at the number on the back of the patient’s ID card.
- By visiting the National Society of Genetic Counselor’s website at NSGC.org. Once there, please ensure you check the “Genetic Counselor: Certified” box at the bottom of the page. Please note, however, that these search results may include non-participating genetic counselors as well as counselors who work for a laboratory.
Please contact genetic counselors prior to receiving services to confirm that they participate in Cigna's network.
- Value of Genetic Counseling
- Genetic counselors are masters-level board-certified health care professionals with specialized training in clinical genetics and counseling.
- Genetic counselors help patients understand the complexities of genetic information, make informed decisions about genetic testing, and make lifestyle or medical adjustments consistent with their religion, culture, and personal beliefs.
- Genetic counselors also encourage compliance with published medical management guidelines and also ensure the appropriate use and interpretation of genetic tests.
- Including genetics specialists on a multidisciplinary team provides support to other health care professionals who want to stay informed of current genetics literature and guidelines.
- Helpful tips for ordering physicians
- To determine if your patient’s plan requires precertification for these tests, please look for “Outpatient Procedures” listed on the back of their Cigna ID card.
- If you call us to precertify these genetic tests, we will remind you that genetic counseling should be performed by a participating independent board-certified genetic counselor or clinical geneticist prior to any service being performed.
- Blood or specimens should not be collected until after the precertification request is made, the genetics professional has made a recommendation regarding the test, and we have approved the precertification request.
- Informed DNA
To help ensure that individuals have ready access to genetics experts and expedited services, we have established a relationship with InformedDNA. InformedDNA is a nationwide network of participating independent board-certified genetic counselors who deliver services via telephone or web. Day, evening, and weekend appointments are available for individuals by telephone at home, and consultations for patients with urgent surgical or treatment decisions are scheduled within 24-48 hours of referral. InformedDNA can be reached by calling 1.800.975.4819
- After the referral
Once the ordering physician refers their patient to an independent board-certified genetic counselor or clinical geneticist, we will typically receive the clinical documentation for the counseling directly from the genetics professional.
In order to help genetic counselors and clinical geneticists facilitate their reviews, we will provide them with a Genetic Counseling Recommendation Form and Whole Exome Sequencing Recommendation Form that will help them to clearly and efficiently make their recommendation regarding the proposed test. We will then use that recommendation and clinical documentation as part of our decision to approve or deny the precertification request.
- Precertification decisions
Each precertification decision will be handled as follows:
- If the precertification request is approved, we will inform the ordering physician and a genetics professional can facilitate the specimen collection, genetic testing, and result interpretation. They will then refer the patient back to the ordering physician for ongoing management, providing them with a consultation report.
- If the ordering physician submits a precertification request for genetic testing and the genetic counselor’s recommendation is not to proceed with testing, we will call the ordering physician to discuss the request. At that time, the physician may withdraw the request, or ask for a coverage determination to be made. If the precertification request is denied, standard appeal rights will be offered.
- Timeframe to get genetic counseling
We will do everything possible to help individuals receive the care they need as soon as they need it. We understand that many tests, especially the BRCA test, may be urgent. That’s why customers have access to many board certified-genetic counselors and clinical geneticists in our network.
Additionally, to help ensure that individuals have efficient access to genetics experts and expedited services, they can contact InformedDNA at 1.800.975.4819.
- Additional useful info
- For the most current list of participating laboratories in an individual’s area, please click on “Find a doctor” at the top of this page.
- For a complete, up-to-date list of services that require precertification of coverage, health care professionals can log in to our Cigna for Health Care Professionals website at CignaforHCP.com and click on “Precertification Policies” under “Popular Links.” Once there, please see the “Master Precertification Policy” document.
- To view a list of monthly precertification updates, health care professionals can review the “Notification of Changes to Precertification List” section on that same page.
- For more information about our coverage policies, including a full copy of our most up-to-date coverage policies, please visit the Medical Policy Index on our CignaforHCP.com website.
- Physicians who are not registered for our website CignaforHCP.com may register by going to CignaforHCP.com and clicking on “Register Now” in the center of the screen.
- For more information
If a health care professional does not have Internet access to view these updates or if they would like additional information about our Genetic Testing and Counseling Program, they should contact their local Market Medical Executive or call Cigna Customer Service at 1.800.88Cigna (882.4462).
Customers can contact Customer Service at the telephone number on the back of their ID card for additional information about this program, or if they need help finding a participating independent board-certified genetic counselor.