New policy for the eviCore Lab Management Program for Medicare Advantage members

As a reminder, effective January 1, 2021, Independence is expanding its utilization management program for genetic/genomic tests, certain molecular analyses, and cytogenetic tests for all Independence Medicare Advantage members. We are working with eviCore healthcare (eviCore), an independent specialty benefit management company, to manage precertification and/or prepayment coverage reviews for these tests.

For more information on the program, please refer to the following Medicare Advantage policy #MA06.034: eviCore Lab Management Program, which was posted as a Notification on December 1, 2020, and will go into effect on January 1, 2021.

To view the Notification for this policy, visit our Medical and Claim Payment Policy Portal.

Summary of Lab Management Clinical Guidelines changes effective January 1, 2021

There are five new guidelines. Thirty-four existing guidelines have been revised (including 21 with substantive criteria changes). Fifteen guidelines were retired.

Below is a summary of the guideline changes:

New Guidelines:

1. Microsatellite Instability and Immunohistochemistry Testing in Cancer
2. Chromosomal Microarray for Solid Tumors
3. Medically Necessary Laboratory Testing
4. Lyme Disease Testing
5. In-vitro testing for HIV

Retired Guidelines:

1. Lynch Syndrome Tumor Screening - First-Tier
2. CYP2C19 Variant Analysis for Clopidogrel Response
3. CYP2C9, VKORC1, and CYP4F2 Testing for Warfarin Response
4. CYP2D6 Variant Analysis for Drug Response
5. DPYD Variant Analysis for 5-FU Toxicity
6. HLA.B*1502 Variant Analysis for Carbamazepine and Oxcarbazepine Response
7. HLA.B*5701 Genotyping for Abacavir Hypersensitivity
8. TPMT Testing for Thiopurine Drug Response
9. UGT1A1 Mutation Analysis for Irinotecan Response
10. SensiGene
11. KRAS Testing for Anti-EGFR Response in Metastatic Colorectal Cancer
12. BRAF Testing for Colorectal Cancer
13. BRAF Testing for Melanoma Kinase Inhibitor Response
14. EGFR Testing for Non-Small Cell Lung Cancer TKI Response
15. FoundationOne CDx

Criteria Updates (Substantive):

1. BRCA Analysis
2. BRCA Ashkenazi Jewish Founder Mutation Testing
3. HLA Typing for Celiac Disease
4. Decipher Prostate Cancer Classifier
5. Genetic Testing for Autism
6. Genetic Testing to Diagnose Non-Cancer Conditions
7. Genitourinary Conditions Molecular Testing
8. Hereditary Cancer Syndrome Multigene Panels
9. Investigational and Experimental Molecular/Genomic
10. Li-Fraumeni Syndrome Testing
11. Liquid Biopsy Testing – Solid Tumors
12. Long QT Syndrome Testing
13. Mammaprint 70.Gene Breast Cancer Recurrence Assay
14. Multiple Endocrine Neoplasia Type 2 (MEN2)
15. Pharmacogenomic Testing for Drug Toxicity and Response
16. Somatic Mutation Testing-Solid Tumors
17. Tay-Sachs Disease Testing
18. myChoice CDx
19. Laboratory Claim Reimbursement
20. Exome Sequencing
21. Somatic Mutation Testing - Hematological Malignancies

Criteria Updates (Non-Substantive):

1. Chromosomal Microarray Testing for Developmental Disorders
2. Early Onset Familial Alzheimer Disease (EOFAD) Genetic Testing
3. Genetic Testing for Arrhythmogenic Right Ventricular Cardiomyopathy
4. Genetic Testing for Dilated Cardiomyopathy
5. Genetic Testing for Epilepsy
6. Genetic Testing for Known Familial Mutations
7. Genetic Testing for Non-Medical Purposes
8. Genetic Testing to Predict Disease Risk
9. Hypertrophic Cardiomyopathy Testing
10. OncotypeDX for Breast Cancer Prognosis
11. Hereditary Ataxia Multigene Panel Testing
12. Molecular Respiratory Infection Pathogen Panel (RIPP) Testing
13. Flow Cytometry