Genetic testing denials: when coverage is required and how to appeal
Genetic and genomic testing is one of the most denied service categories. Here is when coverage is required by guideline and how to map the appeal to the insurer's criteria.
Categories that face denial
Hereditary cancer panels (BRCA1/2, Lynch syndrome panel, multi-cancer panels).
Tumor profiling and comprehensive genomic profiling for treatment selection.
Carrier screening, expanded carrier screening, and prenatal cell-free DNA.
Pharmacogenomic testing.
Where guidelines support coverage
Hereditary cancer testing: NCCN Genetic/Familial High-Risk Assessment guidelines define the family-history and personal-history criteria most plans follow.
Tumor profiling: NCCN and ASCO guidelines define when comprehensive genomic profiling is standard of care for the specific tumor type.
Medicare coverage: NCD 90.2 covers Next Generation Sequencing for advanced cancer when specific criteria are met. See https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=372.
Appeal structure
Pull the insurer's clinical policy bulletin (most are public on the payer's site). Most follow NCCN with minor variations.
Letter of medical necessity from the ordering specialist mapping the patient's family and personal history to each criterion in the bulletin.
If the bulletin requires a board-certified genetic counselor consult, attach the consult note.
For tumor profiling, attach pathology report and stage; cite the specific NCCN treatment-selection recommendation.
Upload the denial letter. Free analysis first, finished letter second.
FAQ
Why was my BRCA test denied even though my mother had ovarian cancer?+
Most policies require the affected relative to be tested first if available, or detailed three-generation pedigree documentation when the relative is deceased or unavailable. Submit the pedigree.
Is pharmacogenomic testing covered?+
Coverage is mixed. CMS covers warfarin and certain psychotropic-related testing under specific LCDs; most commercial plans cover only when there is direct prescribing impact for a specific drug-gene pair.
More guides
- How to write a health insurance appeal letter
- Internal appeal vs external review: what is the difference
- Expedited appeals: when to ask for an urgent review
- The No Surprises Act and out-of-network bills