Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Family History of Breast Cancer. 
Treatment: Genetic testing (unlisted molecular pathology procedure) services. 

The insurer denied coverage for genetic testing (unlisted molecular pathology procedure) services. 

The denial is overturned. 

The patient has no personal history of cancer. Her family cancer history consists of melanoma with sister, and breast cancer with mother, sister, and maternal grandmother. A hereditary cancer predisposition panel was ordered through Myriad's MyRisk panel. Per the patient's appeal, her grandmother and mother are deceased, and she does not have contact with her sister who had breast cancer. 

The health care plan act did not reasonably and with sound medical judgment and in the best interest of the patient. 

The genetic testing (unlisted molecular pathology procedure) services provided is considered medically necessary for this patient. 

This genetic testing is considered to be medically necessary. She has two first-degree and one second-degree relative(s) with breast cancer. Per National Comprehensive Cancer Network (NCCN) criteria, she is eligible for genetic testing. Per the patient's appeal, her grandmother and mother are deceased, and she does not have contact with her sister who had breast cancer. Based on this, as no family member is available for testing, it is in the patient's best interest to have this testing performed. Based on National Comprehensive Cancer Network (NCCN) criteria, she is eligible for genetic testing for high-risk breast and/or ovarian cancer susceptibility genes ("BRCA1, BRCA2, CDH1, PALB2, PTEN, and TP53 among others)." This is because she is "an affected or unaffected individual with a first- or second-degree blood relative meeting any of the criteria listed above." That specific criteria is her sister having had "epithelial ovarian cancer (including fallopian tube cancer or peritoneal cancer) at any age and her mother having had "Personal history of breast cancer with specific features: [less than or equal to] ... Regardless of her age, "greater than or equal to three total diagnoses of breast cancer in patient and/or close blood relatives" meets criteria. This is also recommended by the American College of Obstetricians and Gynecologists and the American Society for Clinical Oncology. Therefore, the genetic testing (unlisted molecular pathology procedure) services provided is considered medically necessary for this patient. 

The National Comprehensive Cancer Network (NCCN) criteria for genetic testing do not specify that an affected family member must be tested first. 

Per American College of Gynecology (ACOG), "Clinical genetic testing for gene mutations allows more precise identification of those women who are at an increased risk of inherited breast cancer and ovarian cancer. For these individuals, screening and prevention strategies can be instituted to reduce their risks." 

Per Excellus's criteria, "genetic testing of an individual who does not have breast cancer, policy statement I: testing should be performed in the family member with a personal history of cancer (affected) first unless an unaffected individual has a family history of a known mutation." 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the genetic testing (unlisted molecular pathology procedure) services provided is overturned. Medical Necessity is substantiated.