Policies & Forms
Letters of Medical Necessity
- Medical Necessity Form
- Chromosomal Microarray Analysis
- Chromosomal Microarray Analysis – HR + SNP Screen (Comprehensive)
- Chromosomal Microarray Analysis – Clinical Gap/Out of Network Exception Request Letter
- GeneAware™ Clinical Gap/Out-of-Network Exception Letter
- Whole Exome Sequencing
- Whole Exome Sequencing Clinical Gap/Out-of-Network Exception Letter
The Aetna Prior Authorization form must be filled out and signed by the ordering physician and sent along with the requisition. This form is only required for tests that include the BRCA1 and/or BRCA2 genes listed below.
- B361 BRCA1/2 Ashkenazi Founder Mutation Panel
- B362 BRCA1/2 Sequencing and Deletion/Duplication
- B502 BRCA1/2 Sequencing
- B501 BRCA1/2 Deletion/Duplication (Only if Aetna Medicare)
- B275 Comprehensive Cancer Panel
- B751 High/Moderate Risk Panel B521 Breast Cancer High-Risk Panel
The Aetna Whole Exome Sequencing (WES) Precertification Information Request form replaces all other WES recertification request documents and forms. Failure to complete this form and submit all of the medical records Aetna requests may result in the delay of review.
Cigna requires their Cigna genetic counseling recommendation form be filled out for genetic testing. This form must be completely filled out by a GCN, APNG, or board certified Genetic Counselor.
UHC (United Healthcare)
Beginning January 1, 2016, UHC requires prior authorization form for BRCA testing to be filled out for genetic testing. This form must be completely filled out by one of the following:
- Genetic Counselor
- Advanced Genetics Nurse
- Genetic Clinical Nurse
- Advanced Practice Nurse in Genetics
- A board-eligible or board-certified clinical geneticist
- A physician with experience in cancer genetics (defined as providing cancer risk assessment on a regular basis and having received specialized ongoing training in cancer genetics. Educational seminars offered by commercial laboratories about how to perform genetic testing are not considered adequate training for cancer risk assessment and genetic counseling).
We are a certified Medicare provider. The patient must meet Medicare’s specific testing criteria for genetic tests. A completed Advanced Beneficiary Notification (ABN) form is required if the patient does not meet the criteria.