Why Aetna Denies Genetic / Genomic Testing
Test not considered medically necessary for this diagnosis
Does not meet hereditary cancer testing criteria
Results will not change treatment plan
Know Aetna's Criteria
Aetna uses their own Clinical Policy Bulletins (CPBs) and InterQual criteria. CPBs are publicly available and numbered.
Key policies to know:
- Clinical Policy Bulletins (CPBs) are publicly available and numbered
- Uses eviCore for radiology and cardiology prior auth
- Known for detailed, evidence-based CPBs with specific criteria
- Precertification list updated annually
Building Your Medical Necessity Argument
Document how test results will directly change management
Meet NCCN testing criteria (family history, age, tumor type)
Reference specific actionable mutations being tested
Note FDA-approved companion diagnostics if applicable
P2P Call Tips for Aetna
Reference the specific CPB number and criteria being met
Aetna CPBs are very detailed -- read them before the call
Address each specific criterion in the CPB during the P2P
Aetna medical directors are typically receptive to guideline-based arguments
Guidelines to Reference
- NCCN Genetic/Familial High-Risk Assessment Guidelines
- CMS NCD for Next Generation Sequencing
Relevant CPT Codes
Specialty: Oncology / Medical Genetics
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