Harvard Pilgrim HealthCare Medical Policy

Whole Genome Sequencing

Subject:

Whole Genome Sequencing

Background:

Harvard Pilgrim Health Care has delegated utilization management of whole genome sequencing testing to Carelon Medical Benefits Management (Carelon)

Whole genome sequencing (WGS) is the analysis of the DNA content of an individual’s genome, used to establish a diagnosis in individuals with especially complex and severe phenotypes. In the pediatric outpatient setting, when either whole exome sequencing (WES) or CMA is being considered, patients may benefit from the broader testing capability provided by WGS. Given these benefits, HPHC covers WGS for individuals under 18 years of age in the outpatient setting who meet Carelon whole exome sequencing (WES) guideline criteria. WGS is recommended over either WES or CMA in this population.

Authorization:

Prior authorization is required for whole genome sequencing provided to members enrolled in commercial (HMO, POS, PPO), products through Carelon

Policy and Coverage Criteria:

• Whole Genome Sequencing
• Whole Genome Sequencing
• Whole Genome Sequencing in members under the age of 18 in the outpatient setting is considered medically necessary when the member meets coverage criteria for whole exome sequencing outlined in the Carelon Clinical Appropriateness Guidelines for Whole Exome and Whole Genome Sequencing https://providers.carelonmedicalbenefitsmanagement.com/point32health/