Effective July 3, 2017, updated AmeriHealth Lab Management Clinical Guidelines will be used by CareCore National, LLC d/b/a eviCore healthcare (eviCore).
AmeriHealth requires precertification and/or prepayment coverage reviews through eviCore for genetic/genomic tests, certain molecular analyses, and cytogenetic tests for all members. eviCore will use the updated Lab Management Clinical Guidelines to determine the medical necessity for these tests. For the current guidelines, go to the following eviCore web pages:
Lab management policy and guidelines
You can now review Medical Policy #06.02.52e: eviCore Lab Management Program, which was posted as a Notification on June 1, 2017, and goes into effect July 3, 2017. The policy includes a summary of the guideline changes and a link to the Lab Management Program Clinical Guidelines that eviCore uses during the precertification and prepayment review processes, as well as a listing of procedure codes that require precertification and/or prepayment review.
To view the Notification for this policy, visit our Medical Policy Portal and select Accept and Go to Medical Policy Online. Then select Commercial under Active Notifications.
Requesting precertification
You can initiate precertification for genetic/genomic tests in one of the following ways:
- NaviNet® web portal. Select CareCore from the Authorizations option in the AmeriHealth Workflows menu.
- Telephone. Call eviCore directly at 1-866-686-2649.
Summary of Lab Management Clinical Guidelines changes effective July 3, 2017
There are 14 new guidelines and 13 revised guidelines with changes in the criteria sections. Seven guidelines were retired and/or replaced. Additional guidelines have been updated and/or revised, but these changes do not affect the criteria sections.
New guidelines:
- Hereditary (Germline) Testing After Tumor (Somatic) Testing
- Neurogenic Muscle Weakness, Ataxia, and Retinitis Pigmentosa (NARP)
- Mitochondrial DNA Deletion Syndromes
- Mitochondrial Neurogastrointestinal Encephalopathy (MNGIE)
- Myoclonic Epilepsy with Ragged Red Fibers (MERRF)
- BCR-ABL Negative Myeloproliferative Neoplasm Testing
- Gene Expression Profiling Tests for Prostate Cancer
- BRCA Analysis
- Myeloma Prognostic Risk Signature (MyPRS)
- Cxbladder
- Whole Exome Sequencing
- EndoPredict for Breast Cancer Prognosis
- Sept9 Methylation Analysis for Colorectal Cancer
- Gene Expression Profiling for Uveal Melanoma
Criteria changes:
- Genetic Testing via Multi Gene Panels
- Ashkenazi Jewish Carrier Screening
- Leber Hereditary Optic Neuropathy (LHON) Genetic Testing
- Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like Episodes (MELAS) Genetic Testing
- Chromosomal Microarray Testing For Developmental Disorders
- CADASIL Testing
- BRCA Sequencing for Drug Treatment Response in Ovarian Cancer (previously BRCA Sequencing for Olaparib Response)
- Genetic Testing for Prenatal Screening and Diagnostic Testing
- Non-Invasive Prenatal Testing
- Investigational and Experimental Molecular/Genomic
- BRAF Testing for Melanoma Kinase Inhibitor Response
- BRAF Testing for Colorectal Cancer
- AlloMap Gene Expression Profiling For Heart Transplant Rejection
Retired guidelines:
- Prolaris for Prostate Cancer Prognosis
- BRCA Known Familial Mutation Analysis
- BRCA Sequencing
- BRCA1/2 Deletion/Duplication Analysis
- CADASIL Known Familial Mutation Analysis
- EndoPredict
- Whole Exome Sequencing
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