What is Genomic Testing and Who Does It Serve?
Genomic testing is a relatively new field of genetics that refers to the process of observing the genes that make up an organism (genome). A person has about 25,000 different genes that are made up of some 3 billion DNA units. Genomic testing differs from genetic testing because it looks at all of a person’s genes instead of a specific gene. Genomic testing looks for any harmful changes in a person’s genetic code. Cancers contain mutations in the genetic code which cause the cancerous cells to grow and spread, leading to tumor development.
Genomic testing can identify specific genetic mutations in a person’s cancer which leads to a better understanding of the specific cancer, as well as how to treat it. Mutations and errors in our DNA are present only in the cancerous cells, which is what genomic testing discovers. Genomic testing is usually done through a blood sample that looks for inherited genetic changes—the specific makeup of a person’s genes that could potentially affect their risk of cancer. If inherited gene mutations are found, other family members could also have the mutation.
What Types of Conditions Require Genomic Testing?
Genomic testing has a wide array of uses including determining the risk of developing specific diseases, screening, and even medical treatment. Genomic testing is especially used to detect (or provide the risk of developing) breast, prostate, colon, and ovarian cancers. Diagnostic genomic testing can be used to investigate an observed phenotype, which refers to an individual’s unique physical and behavioral characteristics.
As an example, diagnostic genomic testing can find germline mutations (changes to DNA inherited during conception), as well as somatic mutations (changes to DNA occurring after conception). These mutations can lead to conditions that affect your health, thus genomic testing allows for earlier detection and treatment. Genomic testing can even determine how you will respond to a specific drug, allowing a doctor to alter medications and dosage, particularly during cancer treatments.
Does Insurance Cover Genomic Testing and Why Are Claims Denied?
Although genomic medicine has the capacity to truly revolutionize medical diagnoses and treatments, there is not yet a systematic agreement across insurers regarding paying for genomic testing. Insurance policies will detail whether genomic testing is covered in general. However, even when it is covered, insurers may go out of their way to find exceptions. They may claim the test was inappropriate, not necessary, or even not scientifically valid. Coding for genomic testing can also cause incorrect denials—there are fewer than 200 Current Procedural Terminology (CPT) codes for more than 7,000 genomic tests.
Which Insurance Companies Are Known to Deny Genomic Testing?
Any insurer—including Anthem Blue Cross, Blue Shield, Aetna, Kaiser, Health Net, UnitedHealthcare, and more—may go out of its way to find a way to deny a claim for genomic testing. One insurer, United Healthcare, faced a lawsuit in 2019 after denying genomic testing that would have allowed health providers to prescribe psychiatric medications that were specifically tailored to the patient’s genetic makeup. At the time, United claimed the tests were experimental or investigational but later agreed to cover genomic testing for mental health issues.
What Should You Do if Your Coverage is Denied for Genomic Testing?
If your insurer has denied coverage for genomic testing that your physician feels is medically necessary, you can appeal that decision. Your doctor will first write a letter to your insurer, asking for a medical exception, and detailing why the testing is medically necessary. If your insurer continues to deny your genomic testing coverage, you can file an appeal with the assistance of an experienced insurance denial attorney from the Law Offices of Scott Glovsky. We have been helping people who face insurance denials for over two decades and will fight zealously for your rights and your health. Contact Scott Glovsky today for a free consultation.