Pre-test and post-test genetic counseling with a provider or a licensed or certified genetic counselor are covered when a member is recommended for covered inheritable genetic testing.
Genetic counseling in connection with pregnancy management is covered only for evaluation of any of the following:
- Couples who are closely related genetically (consanguinity, incest);
- Familial cancer disorders;
- Individuals recognized to be at increased risk for genetic disorders;
- Infertility cases where either parent is known to have a chromosomal abnormality;
- Individuals with primary amenorrhea, azospermia, abnormal sexual development or failure in developing secondary sexual characteristics;
- Mother, known, or presumed carrier of an X-linked recessive disorder;
- One or both parents are known carriers of an autosomal recessive disorder;
- Parents of a child born with a genetic disorder, birth defect, inborn error of metabolism or chromosome abnormality;
- Parents of a child with intellectual developmental disorders, autism, developmental delays or learning disabilities;
- Pregnant women who, based on prenatal ultrasound tests or an abnormal multiple marker screening test, maternal serum alpha-fetoprotein (AFP) test, test for sickle cell anemia, or tests for other genetic abnormalities have been told their pregnancy may be at increased risk for complications or birth defects;
- Pregnant women age 35 years or older at delivery;
- Pregnant women, or women planning pregnancy, exposed to potentially teratogenic, mutagenic or carcinogenic agents (i.e., chemicals, drugs, infections, radiation);
- Previous unexplained stillbirth or repeated (three or more; two or more among infertile couples) first-trimester miscarriages, where there is suspicion of parental or fetal chromosome abnormalities; or
- When contemplating pregnancy, either parent affected with an autosomal dominant disorder.
Genetic counseling for all other indications is considered experimental and investigational.
Prior authorization by medical plan is required.