Eligibility criteria in private and public coverage policies for BRCA genetic testing and genetic counseling

Genetics in Medicine

Volumn 13, Issue 12, 2011, Pages 1045-1050

  Wang, Grace ^a   Beattie, Mary S ^b   Ponce, Ninez A ^c   Phillips, Kathryn A ^a  

^a UNIVERSITY OF CALIFORNIA   (United States)

^b UNIVERSITY OF CALIFORNIA   (United States)

^c UNIVERSITY OF CALIFORNIA   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; BREAST CANCER; FAMILY HISTORY; FEMALE; GENETIC COUNSELING; GENETIC SCREENING; GENETIC SERVICE; HEALTH CARE POLICY; HUMAN; MALE; MEDICAID; MEDICARE; NUCLEAR MAGNETIC RESONANCE IMAGING; ONCOGENE;

ADULT; BRCA1 PROTEIN; BRCA2 PROTEIN; BREAST NEOPLASMS; ELIGIBILITY DETERMINATION; FEMALE; GENETIC COUNSELING; GENETIC TESTING; HUMANS; INSURANCE COVERAGE; MAGNETIC RESONANCE IMAGING; MEDICAID; MEDICARE; MIDDLE AGED; OVARIAN NEOPLASMS; REIMBURSEMENT MECHANISMS; RISK FACTORS; UNITED STATES;

EID: 82955248030     PISSN: 10983600     EISSN: 15300366     Source Type: Journal    
DOI: 10.1097/GIM.0b013e31822a8113     Document Type: Article

References (57)

1. Berliner JL, Fay AM. Risk assessment and genetic counseling for hereditary breast and ovarian cancer: recommendations of the National Society of Genetic Counselors. J Genet Couns 2007;16:241-260. (Pubitemid 46878636)
2. U. S. Preventive Services Task Force. Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: recommendation statement. Ann Intern Med 2005;143:355-361.
3. Robson ME, Storm CD, Weitzel J, Wollins DS, Offit K. American Society of Clinical Oncology policy statement update: genetic and genomic testing for cancer susceptibility. J Clin Oncol 2010;28:893-901.
4. National Comprehensive Cancer Network. Genetic/familial high-risk assessment: breast and ovarian, version 1, 2011. Practice guidelines. Available at: http://www.nccn.org. Accessed May 12, 2011.
5. American College of Medical Genetics Foundation. Genetic susceptibility to breast and ovarian cancer: assessment, counseling, and testing guidelines, 1998. Available at: www.health.state.ny.us/nysdoh/cancer/obcancer/contents.htm. Accessed July 15, 2011.
6. National Comprehensive Cancer Network. Breast cancer screening and diagnosis, version 1, 2011. Practice guidelines. Available at: http://www.nccn.org. Accessed May 12, 2011.
7. Kieran S, Loescher LJ, Lim KH. The role of financial factors in acceptance of clinical BRCA genetic testing. Genet Test 2007;11:101-110. (Pubitemid 46557364)
8. Lee SC, Bernhardt BA, Helzlsouer KJ. Utilization of BRCA1/2 genetic testing in the clinical setting: report from a single institution. Cancer 2002;94:1876-1885. (Pubitemid 34241127)
9. Velicer CM, Taplin S. Genetic testing for breast cancer: where are health care providers in the decision process? Genet Med 2001;3:112-119.
10. Burken MI, Wilson KS, Heller K, Pratt VM, Schoonmaker MM, Seifter E. The interface of medicare coverage decision-making and emerging molecular-based laboratory testing. Genet Med 2009;11:225-231.
11. Giacomini M, Miller F, O'Brien BJ. Economic considerations for health insurance coverage of emerging genetic tests. Community Genet 2003;6:61-73. (Pubitemid 37323444)
12. Logue LJ. Genetic testing coverage and reimbursement: a provider's dilemma. Clin Leadersh Manag Rev 2003;17:346-350.
13. Ramsey SD, Veenstra DL, Garrison LP Jr, et al. Toward evidence-based assessment for coverage and reimbursement of laboratory-based diagnostic and genetic tests. Am J Manag Care 2006;12:197-202.
14. Schoonmaker M, Bernhardt B, Holtzman NA. Coverage of new genetic technologies: what matters to insurers? Am J Hum Genet 1996;59:A3.
15. Schoonmaker MM, Bernhardt BA, Holtzman NA. Factors influencing health insurers' decisions to cover new genetic technologies. Int J Technol Assess Health Care Winter 2000;16:178-189. (Pubitemid 30263212)
16. Latchaw M, Ormond K, Smith M, Richardson J, Wicklund C. Health insurance coverage of genetic services in Illinois. Genet Med 2010;12:525-531.
17. Garber AM. Cost-effectiveness and evidence evaluation as criteria for coverage policy. Health Aff (Millwood) 2004; suppl web exclusives:W4-284-296.
18. Helfner C. Covered lives. The numbers, 2007. Available at: http://www.hks.harvard.edu/m-rcbg/hcdp/numbers.htm. Accessed May 15, 2010.
19. Kaiser Family Foundation. Total number of medicare beneficiaries, 2008. Availableat: http://www.statehealthfacts.org/comparetable.jsp?typ=1&ind= 290&cat=6&sub=74&sortc=1&o=a. Accessed May 15, 2010.
20. Kaiser Family Foundation. Total medicaid enrollment, FY2007, 2006. Availableat: http://www.statehealthfacts.org/comparetable.jsp?typ=1&ind= 198&cat=4&sub=52&sortc=1&o=a. Accessed May 15, 2010.
21. Aetna. Medical clinical policy bulletins. Available at: http://www.aetna.com/healthcare-professionals/policies-guidelines/ medical-clinical-policy-bulletins.html. Accessed May 12, 2011.
22. Centers for Medicaid and Medicare Services. Medicare coverage database. Available at: http://www.cms.gov/mcd/search.asp?from2=search.asp&. Accessed May 12, 2011.
23. Cigna. Coverage policies/criteria medical & pharmacy index. Available at: http://www.cigna.com/customer-care/healthcare-professional/coverage- positions/index.html. Accessed May 12, 2011.
24. Humana. Medical coverage policies. Available at: http://apps.humana.com/ tad/tad-new/home.aspx?type=provider. Accessed May 12, 2011.
25. State of California Department of Health Care Services. Provider manuals. Available at: http://files.medi-cal.ca.gov/pubsdoco/manuals-menu.asp. Accessed May 12, 2011.
26. UnitedHealthcare. Medical & drug policies and coverage determination guidelines. Available at: https://www.unitedhealthcareonline.com/b2c/CmaAction. do?channelId=016228193392b010VgnVCM100000c520720a-Accessed May 12, 2011.
27. Arizona Health Care Cost Containment System (AHCCCS). AHCCCS medical policy manual (AMPM). Available at: http://www.azahcccs.gov/shared/ MedicalPolicyManual/MedicalPolicyManual.aspx. Accessed May 12, 2011.
28. New York State Department of Health. Provider manuals. Available at: http://www.emedny.org/providermanuals/index.html. Accessed May 12, 2011.
29. Aetna. BRCA testing, prophylactic mastectomy, and prophylactic oophorectomy. Clinical policy bulletin, 2010. Available at: http://www.aetna. com/cpb/medical/data/200-299/0227.html. Accessed May 12, 2011.
30. Aetna. Genetic counseling. Clinical policy bulletin, 2010. Available at: http://www.aetna.com/cpb/medical/data/100-199/0189.html. Accessed May 11, 2011.
31. Arizona Health Care Cost Containment System (AHCCCS). Chapter 300: medical policy for AHCCCS covered services. Available at: http://www.azahcccs. gov/shared/Downloads/MedicalPolicyManual/Chap300.pdf. Accessed May 12, 2011.
32. Cigna. Genetic testing for susceptibility to breast and ovarian cancer (e.g., BRCA1 & BRCA2). Cigna medical coverage policy, 2010. Available at: http://www.cigna.com/customer-care/healthcare-professional/coverage-positions/ medical/mm-0001-coveragepositioncriteria-genetic-testing-for-breast-and-ovarian- cancer.pdf. Accessed May 12, 2011.
33. Cigna. Genetic counseling. Cigna medical coverage policy, 2011. Available at: http://www.cigna.com/customer-care/healthcare-professional/coverage- positions/medical/mm-0297-coveragepositioncriteria-genetic-counseling.pdf. Accessed May 12, 2011.
34. Humana. Genetic testing and counseling for hereditary cancer syndromes. Medical coverage policy, 2011. Available at: http://apps.humana.com/tad/tad-new/ Search.aspx?criteria=genetic&searchtype=freetext. Accessed May 12, 2011.
35. Illinois Department of Healthcare and Family Services. Reimbursement for genetic counseling services rendered by genetic counselors. Informational notice, 2008. Available at: http://www.hfs.illinois.gov/html/101408genetic.html. Accessed May 12, 2011.
36. New York State Department of Health. Fee schedule. Laboratory manual, 2010. Available at: http://www.emedny.org/ProviderManuals/Laboratory/index.html. Accessed May 12, 2011.
37. Noridian Administrative Services. Genetic testing. Local coverage determination, 2010. Availableat: http://www.cms.gov/medicare-coverage-database/ details/lcd-details.aspx?LCDId=23664&ContrId=35&ver=29&ContrVer= 1&Search Type=Advanced & CoverageSelection=Local & PolicyType=Both&s=56&KeyWord=genetic & KeyWordLookUp=Doc & KeyWordSearchType=Exact&kq=true&bc=IAAAABAAAAAA&. Accessed May 12, 2011.
38. State of California Department of Health Care Services. Pathology: billing and modifiers. Provider manuals, 2011. Available at: http://files.medi-cal.ca.gov/pubsdoco/manuals-menu.asp. Accessed May 12, 2011.
39. UnitedHealthcare. Genetic testing for hereditary breast and/or ovarian cancer syndrome (HBOC). Medical policy, 2010. Available at: https://www. unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/ Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/ Genetic-Testing-HBOC-Syndrome.pdf. Accessed May 12, 2011.
40. Aetna. Magnetic resonance imaging (MRI) of the breast. Clinical policy bulletin, 2011. Available at: http://www.aetna.com/cpb/medical/data/100-199/ 0105.html. Accessed May 12, 2011.
41. Cigna. Magnetic resonance imaging (MRI) of the breast, 2010. Available at: http://www.cignacom/customer-care/healthcare-professional/coverage- positions/medical/mm-0155-coveragepositioncriteria-mri-of-the-breast.pdf. Accessed May 12, 2011.
42. Humana. Breast magnetic resonance imaging (MRI). Medical coverage policy, 2010. Available at: http://apps.humana.com/tad/tad-new/Search.aspx?criteria= MRI&searchtype=freetext. Accessed May 12, 2011.
43. UnitedHealthcare. Physician guidelines: current, evidence-based recommendations regarding imaging, 2010. Available at: https://www. unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ ProviderStaticFiles/ProviderStaticFilesPdf/Clinician%20Resources/ Radiology%20Notification%20Program/Radiology%20Notification%20docs/ Evidence-based-Clinical-Guidelines-Imaging.pdf. Accessed May 12, 2011.
44. Illinois General Assembly. Bill status of SB1464, 94th general assembly. Available at: http://www.ilga.gov/legislation/billstatus.asp?DocNum= 1464&GAID=8&GA=94&DocTypeID=SB&LegID=18737&SessionID=50. Accessed May 12, 2011.
45. New York State Assembly. A01431 summary. Available at: http://assembly.state.ny.us/leg/?default-fld=&bn=A01431&Summary= Y&Actions=Y&Votes=Y&Memo=Y&Text=Y. Accessed May 12, 2011.
46. Tyler CV Jr, Snyder CW. Cancer risk assessment: examining the family physician's role. J Am Board Fam Med 2006;19:468-477. (Pubitemid 44577205)
47. Sifri RD, Wender R, Paynter N. Cancer risk assessment from family history: gaps in primary care practice. JFam Pract 2002;51:856.
48. Rich EC, Burke W, Heaton CJ, et al. Reconsidering the family history in primary care. J Gen Intern Med 2004;19:273-280. (Pubitemid 38388939)
49. Wilson BJ, Qureshi N, Santaguida P, et al. Systematic review: family history in risk assessment for common diseases. Ann Intern Med 2009;151:878-885.
50. Berg AO, Baird MA, Botkin JR, et al. National Institutes of Health stateof-the-science conference statement: family history and improving health. Ann Intern Med 2009;151:872-877.
51. Burke W, Culver J, Pinsky L, et al. Genetic assessment of breast cancer risk in primary care practice. Am J Med Genet A 2009;149 A: 349-356.
52. Chivers Seymour K, Addington-Hall J, Lucassen AM, Foster CL. What facilitates or impedes family communication following genetic testing for cancer risk? A systematic review and meta-synthesis of primary qualitative research. J Genet Couns 2010;19:330-342.
53. McGrath BB, Edwards KL. When family means more (or less) than genetics: the intersection of culture, family and genomics. J Transcult Nurs 2009;20:270-277.
54. Orom H, Cote ML, Gonzalez HM, Underwood W 3rd, Schwartz AG. Family history of cancer: is it an accurate indicator of cancer risk in the immigrant population? Cancer 2008;112:399-406.
55. Lesser LI, Krist AH, Kamerow DB, Bazemore AW. Comparison between US Preventive Services Task Force recommendations and Medicare coverage. Ann Fam Med 2011;9:44-49.
56. Henry J Kaiser Family Foundation. Focus on health reform, 2010. Available at: http://www.kff.org/healthreform/upload/8061.pdf. Accessed May 12, 2011.
57. Huang AJ, Gemperli MP, Bergthold L, Singer SS, Garber A. Health plans' coverage determinations for technology-based interventions: the case of electrical bone growth stimulation. Am J Manag Care 2004;10:957-962. (Pubitemid 40040892)