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Updated Medical Necessity Policy: Whole Genome Sequencing/Whole Exome Sequencing to be implemented 12/1/2019

Effective December 1, 2019, HPP will be implementing an updated medical necessity policy: MN.011.C Whole Genome Sequencing (WGS) and Whole Exome Sequencing (WES).

In the previous version of the policy (B) WES is considered to be Experimental/Investigational for the diagnosis and screening of genetic disorders. However, this new version of the policy bulletin will allow coverage for WES when all of the medical necessity criteria listed in the policy section are met. WGS is currently considered Experimental/Investigational for the diagnosis and screening of genetic disorders and this coverage position remains the same. Coding table was updated to include codes 81417 and 81427.

All medical necessity, claim payment and drug policies, including the WGS/WES policy, can be reviewed and downloaded from our Policy Bulletin Library.

HPP’s policy bulletins define medical necessity criteria, coding guidance and coverage positions on topics such as medical services, procedures, DME and therapies. Our claim payment policy bulletins provide reimbursement rules and billing guidelines necessary to ensure timely and appropriate payment, and our drug policies document our position on pharmaceutical topics and drugs.

HPP will create and update policy bulletins as appropriate. New and updated policies are typically published 30 days in advance of actual implementation. We welcome you to review WGS/WES immediately, and we will adhere to this policy position beginning December 1, 2019.

If you have questions, contact our Provider Services Helpline at 1-888-991-9023 (Monday–Friday, 9 a.m.–5:30 p.m.) or your NAM (Network Account Manager).