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Prior Authorization Genetic Counseling Required for BRCA Testing

Dec 11, 2015

UnitedHealthcare will begin requiring genetic counseling from an independent genetics care provider prior to approving coverage for BReast CAncer (BRCA) mutation testing for hereditary breast and ovarian cancer. 

This requirement will become effective January 1, 2016. Genetic counseling for BRCA testing is covered 100 percent as a preventive benefit, with no financial impact to members for the prior authorization requirement. 

UnitedHealthcare’s existing BRCA genetic testing medical policy, in place since 2009, recommends but does not require genetic counseling. Without genetic counseling, patients may misuse BRCA mutation analysis test results, which lead to unnecessary treatments and costs. 

Responsibility for ensuring that the new pre-certification requirement is met falls on ordering physicians, labs conducting the test and genetic counselors. 

Why is UHC requiring this counseling?  
Two important organizations, the United States Preventive Services Task Force and the National Comprehensive Cancer Network, recommend screening patients with a family history of breast and ovary cancers to determine if they should be considered for gene testing.  

Both groups recommend genetic counseling prior to testing for the BRCA1 and BRCA2 gene mutations, the best-known genes linked to breast and ovarian cancer risks. This pre-service counseling may help patients understand the implications of positive and negative test outcomes, which supports better quality care. 

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