Q: Why is it important to have genetic counselors involved in the prior authorization review of genetic tests?

A:  As genetic testing continues its rapid evolution, complexity increases. An almost continuous stream of new genetic tests makes it more difficult for insurers to keep up. It’s critical to have genetic counselors involved in the prior authorization and insurance review process. The range of genetic tests is vast, from single-gene tests to multi-gene panels and whole-genome sequencing. Having professionals who deeply understand both the science of genetics and the nuances of clinical applications is critical.

Genetic counselors are specially trained to assess the clinical appropriateness of genetic tests by considering the patient’s medical history, family history, and the specific genetic conditions being investigated. This specialized knowledge is crucial when reviewing prior authorization requests because it goes beyond simply checking whether a rare, complex test meets a general need—it involves understanding the medical necessity and potential benefits of the specific test for the specific patient.

Q: How can genetic counselors transform the review process to benefit payors?

A: Genetic counselors can significantly benefit payors by improving the efficiency and accuracy of reviews for commonly ordered genetic tests. As genetic testing volume increases, automated decision-making tools are increasingly used to speed up the process. However, the success of these tools relies on capturing precise information, posing the right questions, and accounting for clinical nuances to deliver accurate recommendations. 

InformedDNA employs one of the largest number of genetic counselors in the country. They bring specialized expertise in genetics and patient care, ensuring that automated reviews take into account key factors such as family history, clinical context, and the appropriateness of specific tests. By helping to fine-tune these systems, genetic counselors ensure that payors can make quicker, more accurate decisions, reduce inappropriate testing, and ultimately lower costs while still providing access to clinically useful care for patients.

Q: How do genetic counselors help with complex case reviews or appeals?

A: Genetic counselors are trained to manage cases where the genetic aspects of a disease may not be immediately obvious, or where a test may have broader implications for a family. In these instances, a genetic counselor’s expertise ensures that the decision to approve or deny a test is not based purely on checklists or generalized rules, but on a comprehensive understanding of the genetic factors involved and the overall clinical picture.

For example, consider a case where a patient presents with symptoms of a rare genetic disorder like Ehlers-Danlos syndrome (EDS), a connective tissue disorder that can manifest in a variety of ways – joint hypermobility, skin that bruises easily or even the life-threatening rupture of the organs. There are various forms of this condition, some caused by identifiable genetic variants, and others in which the genetic cause remains unknown. The symptoms are often subtle and can overlap, which makes it difficult to pinpoint whether genetic testing will be beneficial. In this scenario, a genetic counselor can review the patient’s history and the provider’s assessment to determine the likelihood of identifying a causative genetic variant, based on the type of EDS suspected.

This level of personalized assessment provided by our genetic experts at InformedDNA helps ensure that they request genetic testing only when there is a clear clinical indication, avoiding unnecessary testing while ensuring that patients who do need testing are able to access it promptly. The counselor’s expertise in rare genetic diseases and their ability to interpret complex genetic information ensures that decisions are medically sound and tailored to the patient’s unique circumstances.

Q: How can genetic counselors help with navigating the complexities of CPT coding in genetic testing?

A: A critical component of the prior authorization review process, CPT coding, often drives how genetic tests are classified and reviewed by insurers. However, keeping up with appropriate   CPT coding for genetic testing can be particularly demanding when it comes to genetic testing, due to the increasing complexity in testing and identifying the appropriate code(s) to describe it. This is where the experience and knowledge of a genetic counselor is invaluable.

CPT codes for molecular testing were historically non-specific with very few codes available to designate tens of thousands of molecular tests. Over time, more specific CPT codes have been introduced allowing improved specificity to code for an increasingly diverse test landscape. Multi-gene panel tests are more standardly utilized, which has created an additional layer of complexity related to coding. Multi-gene panel tests should be coded with the most specific code that appropriately describes the test performed; typically a Genomic Sequencing Procedure (GSP) or a Proprietary Laboratory Analysis (PLA) code which is unique to the proprietary test. In some cases, 81479, the code for unlisted molecular pathology procedures, maybe the most appropriate. Genetic counselors can help ensure the appropriate use of CPT codes and limit abusive practices such as the use of stacked codes for multi-gene panel tests instead of the most specific, single code that can appropriately represent the multi-gene panel test.

Q: How do genetic counselors use their specialized training and evidence-based reviews to make informed decisions when reviewing genetic test prior authorizations?

A: At InformedDNA, where we have helped optimize the health benefits of over 150 million covered lives, evidence-based decision-making is at the core of our utilization management process. Our genetic counselors rely on the latest research and professional society guidelines to assess requests for genetic testing, ensuring that decisions are grounded in the most current and comprehensive evidence. Whether reviewing requests for hereditary cancer syndromes, somatic tumor testing, or rare disease diagnostics, we align with validated data and expert recommendations to provide the most appropriate recommendations for each patient.

A genetic counselor’s specialized training is key to improving the accuracy of these reviews. With a deep understanding of genetics, our counselors can evaluate the clinical relevance of a test in the context of an individual’s case. They assess whether a test is necessary and appropriate based on the patient’s medical and family history, ensuring that decisions are not just based on generic rules but on a thorough, personalized evaluation. This combination of evidence-based review and clinical expertise results in more precise, timely, and efficient prior authorization decisions, helping insurance companies manage complex genetic testing requests while ensuring patients receive the care they need without unnecessary delays or denials.

Q: How does InformedDNA’s genetic counseling expertise benefit insurance payors?

A: Insurance companies benefit from having a genetic counselor involved in the review process because it helps reduce unnecessary claim denials and appeals. At InformedDNA, our genetic counselors understand the intricacies of genetic testing and provide clear, evidence-based justifications for why certain tests should be covered. This results in fewer misunderstandings between insurance providers, healthcare providers, and patients.

Additionally, because genetic counselors at InformedDNA have experience with a wide range of genetic tests and conditions, they can quickly identify any potential issues in a request and ensure that tests are being ordered in accordance with current clinical guidelines. This minimizes the risk of errors, reduces administrative burdens, and speeds up the process for patients, healthcare providers, and insurance companies.