Why MA Plans 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 Medicare Advantage's Criteria
Medicare Advantage plans must cover all services covered by Original Medicare (CMS NCDs and LCDs) but may require prior auth. Plans use various criteria including InterQual, MCG, and proprietary guidelines.
Key policies to know:
- Must cover all services covered by Original Medicare
- Can require prior authorization not required by Original Medicare
- CMS NCDs and LCDs serve as coverage floor
- Organization determinations must be issued within 14 days (72 hours for expedited)
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 MA Plans
Cite the relevant CMS NCD or LCD -- MA plans cannot deny what Medicare covers
If the service has a CMS NCD, that trumps the MA plan's internal criteria
Reference CMS regulations on MA coverage obligations
Request expedited determination if clinical urgency exists
Guidelines to Reference
- NCCN Genetic/Familial High-Risk Assessment Guidelines
- CMS NCD for Next Generation Sequencing
Relevant CPT Codes
Specialty: Oncology / Medical Genetics
Want the full strategy?
The P2P Playbook covers payer-specific approaches for Genetic / Genomic Testing denied by MA Plans -- plus 15 denial objections with word-for-word responses, what reviewers are actually thinking, and the 60-second prep framework. Written by a medical director who reviewed cases for major payers.
Get The P2P Playbook -- $39Get a personalized P2P script in 60 seconds
Enter your specific case details and our AI generates a structured prep script tailored to MA Plans's criteria.