Brca 1 And Brca 2 Genetic Testing denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing for cancer susceptibility. Findings: The physician reviewers found that according to the National Comprehensive Cancer Network (NCCN) guidelines, patients who are “meeting one or more of these criteria warrants further personalized risk assessment, genetic counseling, and often genetic testing and management.” In this case, the patient has a maternal grandmother who is a third degree relative diagnosed with breast cancer at age 72. This patient has two daughters who are second degree relatives, one of whom was diagnosed with breast cancer at age 47, the other diagnosed with ovarian cancer at age 26. Thus, the NCCN criteria are met in the patient’s maternal grandmother and the patient meets criteria for BRCA1 and BRCA2 testing based on NCCN guidelines that pertain to family history.

A 45-year-old female has requested genetic testing for breast cancer gene for evaluation of her risk for developing breast cancer. Findings: Two physician reviewers found that the patient is a 45-year-old female with a significant family history of breast cancer. Her mother had breast cancer at 80, as did her maternal grandmother at 60 years of age, and her maternal aunt at 65. The patient does not have a diagnosis of breast cancer. BRCA testing is important in clinical oncology because bilateral mastectomy would eliminate a patient’s chance of developing breast cancer. Likewise, closer surveillance for ovarian cancer can be enacted, or the patient may choose salpingo-oophorectomy, which would reduce the probability of developing this cancer. The U.S.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing (CPT 81162 and 81307). Findings: The physician reviewer found that patients with BRCA1 mutations can be at increased risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. In addition, BRCA2 mutations can increase a patient’s risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests are negative, there is still a possibility of hereditary predisposition from another gene defect. This patient has a history of one a maternal grandmother with breast cancer, but there is no other history that indicates the presence of a cancer syndrome. In this clinical setting, the recommended course of action includes genetic counseling followed by ordering the appropriate testing.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for BRCA1 and BRCA2 genetic tests (CPT codes: 81408, 81479, 96040, 81162, 81211, and 81213). While there is benefit in BRCA2 testing in males at risk for cancer, a full genetic work-up is not consistent with the current recommendations. This patient has no known personal risk of cancer. His mother has a history of cancer with a BRCA2 mutation. Given the presence of a specific genetic mutation in his family, testing of the specific mutation identified in his mother is appropriate. Males with BRCA2 mutations are known to have increased risk of breast cancer and prostate cancer. Identification of a BRCA2 mutation in this patient would lead to increased screening or higher index of suspicion should symptoms develop. The records do not support full panel genetic testing as requested.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Brca 1 And Brca 2 Genetic Testing, then check the rights and deadlines that apply to your plan.