Harvard Pilgrim has developed and established a medical policy for genetic testing, which includes newborn screening, diagnostic testing, carrier testing, prenatal testing, preimplantation testing, predictive and presymptomatic testing, and forensic testing. The new policy took effect on January 1, 2014.
Harvard Pilgrim will cover genetic tests when the following conditions are met:
- A member displays clinical features or is at direct risk of inheriting a known mutation (pre-symptomatic); or after history, physical examination, pedigree analysis, genetic counseling, and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a gene-linked disease is suspected; and
- The result of a test will directly impact a member’s clinical treatment or management
Some tests, such as preimplantation genetic testing, may require prior authorization; please refer to the appropriate prior authorization medical review criteria for covered indications.
Harvard Pilgrim does not cover genetic testing in the following situations:
- When the testing is used to inform the medical management of an individual’s family member
- To confirm a diagnosis that can be established through other clinical evaluations
- Forensic genetic testing
For the complete information, please see the Genetic Testing Medical Policy.