Genetic Testing for Lynch Syndrome MP9487 Covered Service: Prior Authorization Required: Additional Information: Yes when meets criteria below Yes-as shown below Pre and post test genetic counseling is required for any individual ongoing genetic testing. For ASO members pre and post-genetic counseling is not required. Please reference the ASO Summary Plan Description (SPD). A first-degree relative is defined as an individual s parents, full siblings, and children. A second-degree relative is defined as an individual s grandparents, grandchildren, aunts, uncles, nephews, nieces and half-siblings. A third-degree relative is defined as first cousins, great-aunts, great-uncles, great-grandchildren, or great-grandparents. Medicare Policy: BadgerCare Plus Policy: Dean Health Plan covers when Medicare also covers the benefit. Dean Health Plan covers when BadgerCare Plus also covers the benefit. Dean Health Plan Medical Policy: 1.0 Genetic testing for Lynch Syndrome (EPCAM, MLH1, MSH2, MSH6, and PMS2) requires prior authorization through the Quality and Care Management Division and is considered medically necessary when one (1) of the following (2.0 to 8.0) are met: 2.0 First degree, second degree or third degree relative of person with known EPCAM, MLH1, MSH2, MSH6 or PMS2 gene mutation by DNA sequence testing. 3.0 Personal history of colorectal cancer or endometrial cancer with high microsatellite instability or pathologic immunohistochemistry on cancer tissue testing. 4.0 Personal history in which the revised Bethesda guidelines are met and one of the following are met: 4.1 Colorectal cancer diagnosed under age 50; or Genetic Testing for Lynch Syndrome 1 of 5
4.2 Presence of synchronous (simultaneous), metachronous (diagnosed at different times) colorectal, or other Lynch syndrome related cancer**, regardless of age; or 4.3 Colorectal cancer with the MSI-H histology diagnosed in an individual who is under age 60; or 4.4 Colorectal cancer diagnosed in a patient with one or more first-degree relatives with a Lynch syndrome related cancer**, with one of the cancers diagnosed under age 50; or 4.5 Colorectal cancer diagnosed in a patient with two or more first- or second-degree relatives with a Lynch syndrome related cancer**, regardless of age. 5.0 Personal history of Amsterdam II criteria are met, which includes at least three relatives with a Lynch syndrome related cancer** and ALL of the following: 5.1 One must be a first-degree relative of the other two; and 5.2 At least two successive generations must be affected; and 5.3 At least one of the relatives with Lynch syndrome related cancer** should be diagnosed before age 50; and 5.4 No history of familial adenomatouds polyposis (FAP) in the colorectal cancer cases (if any). 6.0 Individual with endometrial cancer diagnosed before age 50. 7.0 Individual with 5% risk of Lynch syndrome on a mutation prediction model (i. e. MMRpro, PREMM(1,2,6) or MMRpredict). 8.0 The individual has an affected first-degree relative whose cancer diagnosis meets the Amsterdam II criteria which includes at least three relatives with a Lynch syndrome related cancer** and ALL of the following: 8.1 One must be a first-degree relative of the other two; and 8.2 At least two successive generations must be affected; and 8.3 At least one of the relatives with Lynch syndrome related cancer** should be diagnosed before age 50; and 8.4 No history of FAP in the colorectal cancer cases (if any) NOTE:** Lynch-related cancers: colorectal, endometrial, keratocanthoma, stomach, ovarian, small bowel, ureter or renal pelvis, sebaceous adenoma or carcinoma, hepatobiliary, pancreas, brain cancer. Genetic Testing for Lynch Syndrome 2 of 5
CPT/HCPCS Codes Related to MP9487 * Codes on Medical Policy documents are included only as a general reference tool for each policy. This list may not be all-inclusive. 81162 BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene ; full sequence and full duplication/deletion 81201 APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene ; full gene sequence 81203 APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene ; 81288 MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene ; promoter methylation 81292 MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene ; full sequence 81293 MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene ; known 81294 MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene ; 81295 MSH2 (muts homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene ; full sequence 81296 MSH2 (muts homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene ; known 81297 MSH2 (muts homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene ; 81298 MSH6 (muts homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene ; full sequence Genetic Testing for Lynch Syndrome 3 of 5
81299 MSH6 (muts homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene ; known 81300 MSH6 (muts homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene ; 81301 Microsatellite instability (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) of markers for mismatch repair deficiency (eg, BAT25, BAT26), includes comparison of neoplastic and normal tissue, if performed 81317 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene ; full sequence 81318 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene ; known 81319 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene ; 81403 Molecular Pathology Procedure Level 4 81435 Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis); genomic sequence panel, must include sequencing of at least 10 genes, including APC, BMPR1A, CDH1, MLH1, MSH2, MSH6, MUTYH, PTEN, SMAD4, and STK11 81436 Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis); duplication/deletion panel, must include of at least 5 genes, including MLH1, MSH2, EPCAM, SMAD4, and STK11 81479 Unlisted molecular pathology procedure Genetic Testing for Lynch Syndrome 4 of 5
Originated: Revised: Reviewed: Date(s) Committee/Source Medical Policy Committee/Quality and Care Management Division April 3, 2017 Published/Effective: 06/05/2017 Genetic Testing for Lynch Syndrome 5 of 5