Why Anthem BCBS 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 Anthem / Blue Cross Blue Shield's Criteria
Anthem uses their own Clinical UM Guidelines and AIM Specialty Health for imaging. Medical policy numbers are publicly searchable.
Key policies to know:
- AIM Specialty Health manages imaging prior auth
- Clinical UM Guidelines searchable at anthem.com/provider
- Known for strict imaging prior auth requirements
- Uses evidence-based medicine approach with published policies
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 Anthem BCBS
Reference specific Anthem Clinical UM Guideline by policy number
For imaging, address AIM criteria specifically
Anthem medical directors appreciate evidence-based arguments
Cite specific clinical criteria being met from their own policy
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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