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    Health plans explain genetic testing coverage decisions




    John Yao, MD, MPH, MBA, FACP, staff vice president, medical policy development, Anthem, Inc., based in Indianapolis, Indiana, notes that tests may be covered by the payer if clinical criteria are met and include, but are not limited to:

    ·      Hereditary cancer predisposition testing, such as breast cancer susceptibility gene testing for breast and ovarian cancer syndromes;

    ·      Tumor marker analysis for cancer tumor testing to help determine treatment regimens; and

    ·      Prenatal testing, such as cell-free fetal deoxyribonucleic acid testing to evaluate chromosomes and other genetic conditions.

    “It is important to have coverage for genetic tests that provide information that can help manage members’ care and have a positive impact on their overall health and well-being,” Yao says. “Unfortunately, there are many genetic tests for conditions in which no treatments currently exist. Genetic tests that provide information only and do not have an impact on treatment or outcomes can significantly increase the overall cost of healthcare for members, employer groups, and the health plan.”



    Highmark Inc., a Blue Cross and Blue Shield-affiliated organization operating health plans in Pennsylvania, West Virginia, and Delaware, covers many genetics tests that are medically necessary to guide physicians in the proper treatment of a condition. Generally, it covers tests that assist a treating clinician in monitoring and treating patients so that their medical management is optimally based on the best current knowledge, says Marylou Buyse, MD, senior medical director, medical management and policy.


    Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.





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