Genetic testing prior authorization has its own failure modes. The clinical criteria are test-specific and payer-specific. The coding requires DEX Z-codes for MolDX. The documentation burden is heavier than for most services. Get one thing wrong and you're starting over.
Disclaimer: This is educational, not billing, legal, or medical advice. Payer policies change frequently and your situation may differ from the examples here. Always verify current requirements with your payer's most recent published policy and consult qualified billing or compliance professionals. Use this information at your own risk.
Step 1: Identify What You're Requesting and Who the Payer Is
Start here, not at the portal. The payer and the specific test determine everything that comes next.
First, confirm the test type: hereditary (germline) panel, somatic tumor profiling, pharmacogenomics, or a single-gene test. These categories are reviewed under different policies, different clinical criteria, and sometimes different external reviewers.
Next, identify the payer and plan type. Commercial fully insured, self-insured employer (ERISA), Medicare, Medicare Advantage, or Medicaid? The plan type determines which policies apply and which appeal rights you have if things go wrong.
Then look up whether PA is required for this specific CPT code under this specific payer and plan. Don't assume. UnitedHealthcare's PA list differs by employer group. A self-insured client of Cigna may not require PA for a test that Cigna's standard commercial plan requires it for. Check the payer's provider portal or call.
For Medicare patients, check whether the test has an applicable LCD from the MAC covering your region or a National Coverage Determination. For MolDX-managed tests (most molecular diagnostics billed to Medicare in states where Palmetto GBA is the MAC), the test needs a DEX Z-code before billing. If you don't have one, get it through the MolDX technical assessment process before submitting to payer.
Step 2: Find the Coverage Criteria and Map Your Patient Against Them
Pull the payer's current medical policy for the test type. Read the coverage position section — not the background, not the references, the coverage position. Write down every criterion listed.
For hereditary cancer panels, you're typically looking at: personal history of cancer at qualifying age, number of affected first- or second-degree relatives, specific cancer types (ovarian, triple-negative breast, colorectal, uterine), ethnic background criteria, prior genetic test results, or meeting a validated risk assessment threshold. The criteria vary by payer. Aetna, Cigna, and UHC each have different thresholds.
For somatic tumor profiling (NGS of tumor tissue): confirmed malignancy, cancer type, disease stage (usually advanced/metastatic), and that the result will guide treatment selection. Some policies require documentation that targeted therapy options exist for the cancer type.
For pharmacogenomics: this is the hardest category. PGx coverage is narrow across most payers. Most policies cover a limited set of drug-gene pairs for specific clinical situations (pre-transplant medication management, specific psychiatric drug selection). Many policies list PGx as E&I for most indications.
Write out the criteria your patient meets. If they don't meet all criteria, decide now whether to proceed with a documentation-strengthening conversation with the ordering physician or whether this is a case that'll need to go to appeal.
Step 3: Assemble the Documentation Package
Don't submit and then chase documentation. Assemble everything before you open the portal.
For hereditary panels:
- Clinical notes documenting the specific qualifying criterion (personal history, family history, risk assessment score)
- Pathology reports if personal cancer history is the qualifying criterion
- For family history criteria: documentation of the specific relative's diagnosis and relationship, ideally from the patient's chart or a pedigree drawn by a genetic counselor
For somatic tumor profiling:
- Pathology report confirming tumor type, grade, and stage
- Clinical notes documenting advanced or metastatic disease
- Prior treatment history with dates and response
- Statement from the ordering physician explaining what treatment decision the results will inform
For MolDX-managed tests billed to Medicare:
- The test's DEX Z-code (obtained through Palmetto GBA's MolDX program)
- ICD-10 diagnosis codes matching the LCD's covered indications
- Ordering provider's NPI on the ABN if coverage is uncertain
Step 4: Submit — and Track
Submit through the payer's designated channel. Availity handles most commercial payers. Some payers use their own portals. eviCore manages reviews for some payers' NGS panels.
When you submit, record: submission date and time, case/reference number, channel used (portal, fax, EDI), and who submitted. Set a calendar reminder for the expected decision date.
Standard PA timelines under federal rules: 15 calendar days for standard non-urgent requests, 3 business days (72 hours) for urgent/expedited, under ACA-compliant commercial plans and Medicare Advantage. If you don't have a decision by day 14, follow up.
If the payer requests additional information (a "pend"), respond within their stated deadline. Missing it turns a pend into a denial with stricter appeal rights.
Step 5: If You Get a Denial
Read the denial reason before doing anything else. It tells you whether this is a documentation problem (missing criteria), a policy problem (test is E&I or excluded), or a process problem (wrong CPT code, missing NPI).
Documentation problems are the easiest to fix. Get the missing information and file the appeal with a complete clinical package within the appeal deadline.
Policy denials (E&I or benefit exclusion) take longer. You'll need to build an evidentiary case — peer-reviewed literature, FDA clearance status, NCCN listing, positive coverage determinations from other payers. This is a weeks-long process, not days.
Request a peer-to-peer review for medical necessity denials. The ordering physician speaking directly to the payer's medical director is the highest-yield intervention. Don't skip it to go straight to written appeal.
Sources
- CMS NCD 90.2 (next-generation sequencing in cancer)
- Palmetto GBA / MolDX program (DEX Z-code technical assessment requirements)
- 42 CFR §410.32 (Medicare ordering and referring requirements)
- 45 CFR §147.136 (internal claims and appeals — ACA-compliant plans)
- ACA §2719 (independent external review)
- ASCO/CAP HER2 Testing Guidelines — joint guideline
- NCCN Clinical Practice Guidelines (NCCN.org)