Clinical guidelines

Carelon Medical Benefits Management evidence-based clinical guidelines address, but are not limited to tier one and tier two molecular pathology CPT codes. Below, please find a partial list of testing scenarios managed to support high value, high quality molecular diagnostics for Point32Health members covered by the Carelon program.

• Germline genetic testing for diagnosis or disease-risk evaluation
• Somatic mutation and multigene panel testing used to target treatment for cancer and other diseases
• Rare disease testing, including whole exome
• Pharmacogenomic testing
• Testing associated with infertility, preimplantation genetic diagnosis (including 89290 and 89291), and prenatal care
• Testing for cardiac, coagulation, neurogenetic, neuromuscular, and ocular disorders

Carelon clinical appropriateness guidelines are developed by board-certified genetic counselors and medical geneticists through systematic reviews of peer-reviewed resources, medical society guidelines, and practice bulletins. The process for assessing the clinical appropriateness of testing is consistent with the CDC ACCE Model Process for Evaluating Genetic Tests. Guidelines are reviewed and updated at least semi-annually – more frequently if necessitated by new evidence.