The Connection OnlineSM

April 2011

April 2011

Investigational and medical necessity reviews

Note from the editor (4/21/11): A new section was added for Genetic Testing. The policy numbers for the policies in this section were corrected and the links were also fixed.

Listed below are summaries of recent changes to our medical and behavioral health policies. View all detailed policies in the Medical Policy Manual and the Behavioral Health Policy Manual. This list does not include medications or Medicare medical policy exceptions.

New or updated investigational or medical necessity policy criteria

Genetic Testing

Genetic and Molecular Diagnostic Testing (#20)

  • Policy reorganized and separate policies based on indication created.
  • LAB-20 criteria now contains an "index" that provides links to new individual policies. There were no other changes to the criteria in the new separate policies unless identified in this notification.
  • Removed requirement for genetic counseling from the general genetic testing criteria.
  • Clarified criteria concerning documentation requirements.

Genetic Testing for Hereditary Breast and/or Ovarian Cancer (#02)

Policy rewritten to clarify criteria. Added new criteria for BRCA1/2 genomic rearrangement and CHEK2 testing.

KRAS and BRAF Mutation Analysis in Metastatic Colorectal Cancer (#13)

Policy updated to add BRAF testing as a new investigational indication. No changes to criteria for KRAS testing. 


Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer (#61)

New investigational policy on use of systems pathology to predict risk of prostate cancer recurrence.

New or updated investigational or medical necessity policy criteria effective July 1

Vitamin D Testing (#52)

New medical policy defining medical necessity criteria for vitamin D testing. See vitamin D testing article for details.


Radioembolization for Primary and Metastatic Tumors of the Liver (#140)

New policy considers radioembolization as medically necessary for certain liver tumors and investigational for all other liver tumors.

Join our medical policy discussions
We welcome your input and feedback as we draft our medical policies. It's easy to join our email reviewer list. Simply complete our request form.

While we prefer to receive input as policies are developed, we also have a formal process that allows providers to submit additional information, such as clinical trial results, that may warrant a policy review.

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