Transition to Carelon Medical Benefits Management, Inc. Genetic Testing Guidelines

Effective April 1, 2024, Empire BlueCross BlueShield will transition to the following Carelon Medical Benefits Management, Inc.* Genetic Testing guidelines to perform medical necessity/clinical appropriateness reviews for requested genetic tests. Applicable CPT^® codes lists are included in each guideline linked below:

• Carrier Screening in the Prenatal Setting and Preimplantation Genetic Testing
• Cell-free DNA Testing for the Management of Cancer
• Chromosomal Microarray Analysis
• Genetic Testing for Inherited Conditions
• Hereditary Cancer Testing
• Pharmacogenomic Testing
• Polygenic Risk Scores
• Prenatal Testing using cell-free DNA
• Somatic Tumor Testing
• Whole Exome Sequencing and Whole Genome Sequencing

Prior authorization requirements remain the same. The requested services received on or after
March 30, 2024, will be reviewed with the new Clinical Criteria.

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management using the following:

• Carelon Medical Benefits Management ProviderPortal_SM directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.

If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.