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    Health plans explain genetic testing coverage decisions


    Today there are nearly 67,000 genetic tests representing nearly 5,000 disorders and 5,900 genes, according to GeneTests, a medical genetics information resource. With so many tests available, it can be difficult for MCOs to determine what to cover.


    Karen Lewis, MS, MM, CGC, is solution management director, genetic testing, AIM Specialty Health, in Chicago, Illinois, a specialty benefits management company. She says the most important genetic tests to cover are those that provide information that can lead to improved outcomes—including prevention.

    “Certain genetic tests can provide information that not only identifies which treatments will be most effective, but also help patients avoid potentially harmful or even lethal treatments and exposures,” she says. “For tests that meet our medical management and outcomes benchmark, morbidity and mortality is sometimes tremendously reduced. Often, genetic information allows for screening that leads to early detection, reducing the medical and financial impact for both the member and health system. Downstream cost of care savings is greatly increased through targeted therapy and prevention.”

    Here’s how several health plans make genetic coverage decisions.



    Cigna’s approach is to start the coverage evaluation process if it finds that a test is being ordered or completed with some regularity, says Jeffrey Hankoff, MD, medical officer, clinical performance and quality. “We follow the same process for genetic testing coverage policies as we do for all other coverage policies for medications, medical procedures, and medical devices,” he says of the health plan headquartered in Bloomfield, Connecticut. “Policies are based on an extensive examination of peer-reviewed medical and scientific studies, journal articles, and other evidence, as well as suggested guidelines from professional medical societies.”

    Priority Health

    John Fox, MD, MHA, vice president and associate chief medical officer, Priority Health, in Grand Rapids, Michigan, says that demonstrating analytic validity, clinical validity, and most importantly clinical utility, are critical to coverage of prognostic and predictive laboratory testing. “Clinical utility refers to genetic test results that will change provider decision-making and in doing so change clinical outcomes that are meaningful and relevant to the patient,” he says. “Equally important is a test’s affordability, which is dependent on its cost and the number of people who need it.”


    He explains that genetic tests that affect the treatment of fewer individuals (such as one out of every 100 individuals tested), are harder to economically justify than tests that could affect more individuals out of the broader pool (such as one that affects one out of every 10 individuals tested). “A common reason for declining to cover a genetic test is that the cost per treatment impacted is exceptionally high.”

    Priority Health covers genetic tests within four categories:

    ·      Prenatal,

    ·      Prognostic,

    ·      Predictive, and

    ·      Diagnostic.


    Next: What happens at Anthem?



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