Medical Policy


Subject:Genetic Testing for Cancer Susceptibility
Policy #:  GENE.00001Current Effective Date:  01/14/2014
Status:RevisedLast Review Date:  11/14/2013

Description/Scope

This document addresses genetic testing to determine whether an individual is at risk for the development of cancer based on a genetic test.  This document includes criteria which may be used to evaluate the medical necessity of a specific genetic test when there is no other more specific document.

For additional information on genetic testing for malignant conditions, please refer to:

Position Statement

Medically Necessary: 

Note: Genetic testing is appropriate only when offered in a setting with adequately trained health care professionals to provide appropriate pre- and post-test counseling.

Genetic testing for susceptibility to malignant diseases is considered medically necessary when the following criteria are met:

Investigational and Not Medically Necessary:

Genetic testing for cancer susceptibility is considered investigational and not medically necessary in individuals not meeting any of the criteria above.  

Genetic testing for cancer susceptibility using panels of genes (with or without next generation sequencing), including, but not limited to CancerNext™, is considered investigational and not medically necessary unless all components of the panel have been determined to be medically necessary based on the criteria above.  However, individual components of a panel may be considered medically necessary when criteria above are met.

Note: When a component of a genetic panel is separately identified, but a specific medical necessity statement is not in another document, the criteria above may be used to determine medical necessity.

Rationale

Genetic Testing Using Panels of Genes

Until recently, genetic testing for cancer susceptibility was generally carried out by direct sequencing which analyzes a specific gene for a particular mutation.  However, next generation sequencing, (including but not limited to massively parallel sequencing, and microarray testing) has made it possible to conduct panel testing which involves the analysis of multiple genes for multiple mutations simultaneously.  Panel testing has the potential benefit of analyzing multiple genes more rapidly and thereby providing the results of the genetic work-up in a more timely fashion.  However, the newer sequencing techniques may be associated with a higher error rate and lower diagnostic accuracy than direct sequencing which could affect the clinical validity of testing.  Another potential drawback of the newer technologies is that they may provide information on genetic mutations which is of uncertain clinical significance.  In assessing the value of a specific genetic testing panel for susceptibility to a particular malignant condition, consideration should be given to the peer-reviewed, published literature addressing the analytical validity, clinical validity, and clinical utility of the test.  Also, evidence demonstrating a positive impact of the panel on the care of individuals with, or at risk for, a specific cancer should be considered.

Gene Mutations

BARD1 (BRCA1 associated RING domain 1) protein interacts with the BRCA1 gene protein.  The two proteins working together act as tumor suppressors.  The role of BARD1 mutations in cancer risk is unclear, although some research studies suggest that changes in the BARD1 gene may influence an individual's risk of developing breast cancer.

BMPR1A (bone morphogenetic protein receptor, type IA) and SMAD4 gene mutations are associated with juvenile polyposis syndrome (JPS).  JPS is inherited in an autosomal dominant manner and confers an increased risk of developing gastrointestinal cancer.

BRIP1( BRCA1 interacting protein C-terminal helicase 1) protein interacts with the BRCA1 protein.  The two proteins working together act as tumor suppressors.  Some research studies suggest certain inherited mutations in the BRIP1 gene are associated with an increased risk of developing breast cancer.  Fanconi anemia type J (FA-J) is caused by two mutated copies of the BRIP1 gene in each cell. 

CDH1 (cadherin 1, type 1, E-cadherin [epithelial]) germline mutations are characterized by a high risk for stomach and lobular breast cancer.  CDH1 is an autosomal dominant disorder.  The average age of onset of gastric cancer in affected individuals is 38 years old.  The lifetime risk of developing gastric cancer by age 80 is approximately 67% for men and 83% for women. Inherited mutations in the CDH1 gene increase a woman's risk of developing lobular breast cancer.

CHEK2 (checkpoint Kinase 2) gene mutations confer an increased risk of developing several different types of cancer, including breast, ovarian, prostate, colon, kidney and thyroid.  CHEK2 mutations have also been associated with Li-Fraumeni syndrome.

MRE11A (meiotic recombination 11 homolog A) mutations may cause nephronophthisis-related ciliopathies (NPHP-RC), a group of recessive diseases that affect the kidney, retina and brain.  A homozygous truncating mutation MRE11A has been found in individuals with cerebellar vermis hypoplasia, ataxia and dysarthria.

NBN (nibrin) mutations may be associated with an increased risk of developing several cancers including breast, prostate, ovarian, melanoma and leukemia.

RAD50 (RAD50 homolog) gene mutations have been associated with the development of breast cancer.

RAD51C (RAD51 paralog C) gene mutations have been associated with the development of breast cancer.

STK11 (serine/threonine kinase 11) germline mutations have been associated with Peutz-Jegher syndrome (PJS).  Individuals with PJS have an increased risk for the development of noncancerous growths (hamartomatous polyps) in the gastrointestinal tract and an elevated risk of developing certain types of cancer.

Background/Overview

Genetic Testing Using Panels of Genes
Next-generation sequencing addresses any of the technologies that allow rapid sequencing of large numbers of segments of DNA, up to and including entire genomes.  Next-generation sequencing is not a specific sequencing technology or a test in itself.  Instead, the term emphasizes the difference between the earlier testing methods that involved the sequencing of one DNA strand at a time.  Next generation sequencing includes but is not limited to massively parallel sequencing and microarray analysis. 

Next generation sequencing has led to the development of genetic testing incorporating panels which analyze multiple genes for multiple mutations simultaneously.  Researchers are investigating genetic testing using panels of genes as a means to identify genetic mutations that may contribute to the development of hereditary cancers.

Definitions

Ashkenazi Jewish: A term for people of eastern European Jewish heritage.

First-degree relative: Any relative who is a parent, sibling, or offspring to another.

Genetic counseling: A process involving the guidance of a specially trained professional in the evaluation of family history, medical records, and genetic test results, in assessing the risk of genetic diseases, understanding the ramifications of diagnosis, and explanation of available treatment options.

Genetic testing: A type of test that is used to determine the presence or absence of a specific gene or set of genes to help diagnose a disease, screen for specific health conditions, and for other purposes.

Mutation: A change in DNA sequence.

Next-generation sequencing: Any of the technologies that allow rapid sequencing of large numbers of segments of DNA, up to and including entire genomes.  This technology includes but is not limited to massively parallel sequencing and microarray analysis).

Second-degree relative: Any relative who is a grandparent, grandchild, uncle, aunt, niece, nephew, or half-sibling to another.

Third-degree relative: Any relative who is a first cousin, great grandparent or great grandchild.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. 

When Services may be Medically Necessary, when criteria are met: 

CPT 
81404

Molecular pathology procedure, Level 5 (eg, analysis of 2-5 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 6-10 exons, or characterization of a dynamic mutation disorder/triplet repeat by Southern blot analysis)  [when specified as the following]:

  • STK11 (serine/threonine kinase 11) (eg, Peutz-Jeghers syndrome), duplication/deletion analysis
81405

Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons, regionally targeted cytogenomic array analysis)  [when specified as the following]:

  • STK11 (serine/threonine kinase 11) (eg, Peutz-Jeghers syndrome), full gene sequence
81406

Molecular pathology procedure, Level 7 (eg, analysis of 11-25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 26-50 exons, cytogenomic array analysis for neoplasia)  [when specified as the following]:

  • CDH1 (cadherin 1, type 1, E-cadherin [epithelial]) (eg, hereditary diffuse gastric cancer), full gene sequence  
81479Unlisted molecular pathology procedure [when specified as the following: BARD1, BMPR1A, BRIP1, CHEK2, MRE11A, NBN, RAD50, RAD51C]
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
 All malignancy-related diagnoses, including but not limited to
140.0-209.36Malignant neoplasms
V10.00-V10.91Personal history of malignant neoplasm
V16.0-V16.9Family history of malignant neoplasm
V84.01-V84.09Genetic susceptibility to malignant neoplasm
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
 All malignancy-related diagnoses, including but not limited to
C00.0-C96.9Malignant neoplasms
Z15.01-Z15.09Genetic susceptibility to malignant neoplasm
Z80.0-Z80.9Family history of primary malignant neoplasm
Z85.00-Z85.9Personal history of malignant neoplasm

When services are Investigational and Not Medically Necessary:
For genetic susceptibility testing when criteria are not met 

When services are also Investigational and Not Medically Necessary: 

CPT 
81479Unlisted molecular pathology procedure [when specified as testing for cancer susceptibility using panels of genes (with or without next generation sequencing), including, but not limited to CancerNext]
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
 All diagnoses
  
References

Peer Reviewed Publications:

  1. Smith RA, Cokkinides V, Brawley OW.  Cancer screening in the United States, 2009: A review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin. 2009; 59(1):27-41.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. National Library of Medicine (NLM). Genetics Home Reference. Published June 24, 2013. Available at: http://ghr.nlm.nih.gov/ghr/glossary/firstdegreerelative and http://ghr.nlm.nih.gov/ghr/glossary/seconddegreerelative.  Accessed on October 15, 2013.
  2. Robson ME, Storm CD, Weitzel J, et al. American Society of Clinical Oncology position statement update: genetic and genomic testing for cancer susceptibility. J Clin Oncol. 2010; 28(5):893-901. Available at: http://jco.ascopubs.org/content/28/5/893.full.pdf+html.  Accessed on October 15, 2013.
Web Sites for Additional Information
  1. National Library of Medicine (NLM). Genetics Home Reference.  http://ghr.nlm.nih.gov/. Accessed on October 15, 2013.
Index

Genetic testing panels
Genetic testing using panels

Document History
StatusDateAction
Revised11/14/2013Medical Policy & Technology Assessment Committee (MPTAC) review.
Revised11/13/2013Hematology/Oncology Subcommittee review. Clinical content reformatted. Criteria for colorectal cancer susceptibility moved to GENE.00028. Criteria for breast and/or ovarian cancer syndrome moved to GENE.00029. Criteria for genetic testing for endocrine gland cancer susceptibility moved to GENE.00030. Information related to PTEN hamartoma tumor syndrome moved to GENE.00031. Added Note "When a component of a genetic panel is separately identified, but a specific medical necessity statement is not in another document, the criteria above may be used to determine medical necessity". Description/Scope, Rationale, Coding and Index sections updated. Added Web Sites for Additional Information section.
Revised08/08/2013MPTAC review.
Revised07/11/2013Hematology/Oncology Subcommittee review. Added investigational and not medically necessary Position Statement addressing genetic testing for cancer susceptibility using panels of genes (with or without next generation sequencing). Updated Rationale, Background and Overview, Coding References and Index sections of the document. 
Revised05/09/2013MPTAC review.
Revised05/08/2013Hematology/Oncology Subcommittee review. Expanded the medically necessary criteria for BRCA1 / 2. Clarified that "close blood relatives" now defined as first-, second- and third-degree relatives on same side of family. In the section on Lynch Syndrome, removed criterion that the individual has a first- or second-degree relative with a right-sided colorectal cancer with an undifferentiated pattern on histopathology diagnosed prior to age 45; and the individual has a first- or second-degree relative with a signet ring cell type colorectal cancer diagnosed prior to age 45. Modified medically necessary statement for MYH (Human MutY homolog)-associated Polyposis (MAP) to clarify that MYH is also known as MUTYH. Updated rationale and references.
 01/01/2013Updated Coding section with 01/01/2013 CPT changes.
Reviewed08/09/2012MPTAC review. Updated References and History sections. 
Revised06/27/2012MPTAC review.  Coding and References were updated.
Revised06/19/2012Hematology/Oncology Subcommittee review.  Expanded the medically necessary criteria to include large genomic rearrangement testing (BART) when criteria are met and to modify the investigational and not medically necessary language to clarify BART is not covered when criteria are not met.  Clarified BRCA1/2 medically necessary criteria related to "individual with a family history of 3 or more first-, second- or third-degree relatives …".  Expanded the medically necessary criteria for HNPCC (Lynch syndrome) for individuals with a family member who would meet criteria for testing, but that family member is not available.
Revised05/10/2012MPTAC review.  The Rationale, Definitions and References were updated.
Revised05/09/2012Hematology/Oncology Subcommittee review.  In the medically necessary section for BRCA1 and BRCA2, the word 'premenopausal' was changed to 'prior to age 50' and the word 'epithelial' was removed from the criteria.  Deleted Criterion stating "Individuals with a personal history of breast cancer, and diagnosed age less than 50 years with a limited family history."  Updated review date, Description/Scope, Rationale, Definitions, Coding, References and History sections of the document.  Modified language in medical necessity criteria to provide clarity.
 04/01/2012Updated Coding section with 04/01/2012 HCPCS changes; removed codes S3818, S3819, S3820, S3822, S3823, S3828, S3829, S3830, S3831 deleted 03/31/2012.
 01/01/2012Updated Coding section with 01/01/2012 CPT changes.
Revised05/19/2011MPTAC review.
Revised05/18/2011Hematology/Oncology Subcommittee review.  Updated review date, References and History sections. In the selection criteria for BRCA1 and BRCA2, revised the first bullet by removing the word "especially" from the criteria. Added bullets 6 – 9 under the BRCA1 and BRCA2 criteria.
Revised11/18/2010MPTAC review.
Revised11/17/2010Hematology/Oncology Subcommittee review.  Re-organized position statements.  Medically necessary criteria for BRCA1/BRCA2 and HNPCC revised based on NCCN guidelines in clinical oncology. Added general medical necessity criteria for genetic testing for malignant diseases. Revised investigational/not medically necessary criteria to read "Genetic testing for cancer susceptibility is considered investigational and not medically necessary in individuals not meeting any of the criteria in sections I and II above, including but not limited to the BRACAnalysis® Rearrangement Test [BART]." Updated review date, Definitions, Coding, References and History sections.
Revised11/19/2009MPTAC review.
Revised11/18/2009Hematology/Oncology Subcommittee review. Added new position statement stating "Genetic testing for large rearrangements in BRCA1 and BRCA2 genes (BRACAnalysis Rearrangement Test [BART]) is considered investigational and not medically necessary."  Updated review date, Rationale, Coding, Background/Overview, References, Index and History sections.
Revised05/21/2009MPTAC review.
Revised05/20/2009Hematology/Oncology Subcommittee review.  Revised patient selection criteria to reflect more recent recommendations from the American College of Obstetricians and Gynecologists (ACOG) and the National Comprehensive Cancer Network (NCCN). (1) Medical necessity criteria for BRCA1/2 expanded to allow genetic testing for individuals with ovarian cancer, primary peritoneal cancer, or fallopian tube cancer (without having to meet any additional criteria); (2) In bullet #1 under the medically necessary section for MYH-associated Polyposis (MAP), removed the words "at one time" from the patient selection criteria; (3) In bullet #3 under the medically necessary criteria for HNPCC, changed the age limit from less than 45 years to less than 50 years.  Updated review date, References and History sections of the document.
Revised05/15/2008MPTAC review.
Revised05/14/2008Hematology/Oncology Subcommittee review. Modified patient selection criteria based on feedback from external consultants, peer-reviewed scientific literature and professional society guidelines, including, but not limited to the NCCN guidelines.  Updated review date, Background/Overview, References and History sections.  
Revised02/21/2008MPTAC review. Document revised to have GENE.0001 only address genetic testing for cancer susceptibility. Title changed to Genetic Testing for Cancer Susceptibility. Prenatal genetic testing moved to GENE.00012 (Preconceptional or Prenatal Genetic Testing of Parents or Prospective Parents) and diagnostic genetic testing moved to GENE.00013 (Diagnostic Genetic Testing of a Potentially Affected Patient (Adult or Child). Updated review date, Background/Overview, References and History sections. 
Revised11/29/2007MPTAC review. Revised patient selection criteria, rationale, coding and background/overview sections to clarify that genetic testing for ALS is considered INV and NMN. Updated review date, Description, Definitions, and History sections. Added index section. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary."
Reviewed12/07/2006MPTAC review. Updated review date, Coding, Definitions, References and History sections.
 01/01/2007Updated Coding section with 01/01/2007 CPT/HCPCS changes. 
 01/01/2006Updated Coding section with 01/01/2006 CPT/HCPCS changes.
Revised12/01/2005MPTAC review.  Addition of attachment A medical review worksheet to policy. 
Revised09/22/2005MPTAC review.  Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

04/28/2004

GENE.00001Genetic Molecular Testing for Inherited disorders
WellPoint Health Networks, Inc.

06/24/2004

2.01.18Genetic Testing for Cystic Fibrosis
 

06/24/2004

2.11.10Genetic testing for Hereditary Colon Cancer
 

06/24/2004

2.11.09Genetic Testing for Inherited BRCA1 and BRCA2 Mutations
 

04/28/2005

2.01.16  Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease