Hereditary Cancer Syndrome Multigene Panels

Lab Management Guidelines v2.0.2019 Hereditary Cancer Syndrome Multigene Panels

MOL.TS.182.A v2.0.2019 Introduction

Hereditary cancer syndrome multigene panel testing is addressed by this guideline.

Procedures addressed

The inclusion of any procedure code in this table does not imply that the code is under management or requires prior authorization. Refer to the specific Health Plan's procedure code list for management requirements.

Procedures addressed by this Procedure codes guideline APC Sequencing 81201 APC Deletion/Duplication Analysis 81203 ATM Sequencing 81408 BRCA1/2 Sequencing 81163 BRCA1/2 Deletion/Duplication Analysis 81164 BRCA1 Sequencing 81165 BRCA1 Deletion/Duplication Analysis 81166 BRCA2 Sequencing 81216 BRCA2 Deletion/Duplication Analysis 81167 Chromosomal Microarray [BAC], 81228 Constitutional Chromosomal Microarray [SNP], 81229 Constitutional MLH1 Sequencing 81292 MLH1 Deletion/Duplication Analysis 81294 MSH2 Sequencing 81295 MSH2 Deletion/Duplication Analysis 81297 MSH6 Sequencing 81298 MSH6 Deletion/Duplication Analysis 81300 PMS2 Sequencing 81317 PMS2 Deletion/Duplication Analysis 81319

Procedures addressed by this Procedure codes guideline PTEN Sequencing 81321 PTEN Deletion/Duplication Analysis 81323 Hereditary breast cancer-related disorders 81432 (eg, hereditary breast cancer, hereditary

ovarian cancer, hereditary endometrial

cancer); genomic sequence analysis s panel, must include sequencing of at least l 10 genes, always including BRCA1, e BRCA2,CDH1, MLH1, MSH2, MSH6, n PALB2, PTEN, STK11, and TP53 a P Hereditary breast cancer-related disorders 81433 (eg, hereditary breast cancer, hereditary e ovarian cancer, hereditary endometrial n cancer); duplication/deletion analysis e g

panel, must include analyses for BRCA1, i

BRCA2, MLH1, MSH2, and STK11 t l

Hereditary colon cancer disorders (eg, 81435 u Lynch syndrome, PTEN hamartoma M syndrome, Cowden syndrome, familial adenomatosis polyposis); genomic e sequence analysis panel, must include m sequencing of at least 10 genes, including o

APC, BMPR1A, CDH1, MLH1, MSH2, r

MSH6, MUTYH, PTEN, SMAD4, and d

STK11 n

Hereditary colon cancer disorders (eg, 81436 y

Lynch syndrome, PTEN hamartoma S

syndrome, Cowden syndrome, familial r

adenomatosis polyposis); e

duplication/deletion analysis panel, must c

include analysis of at least 5 genes, n

including MLH1, MSH2, EPCAM, SMAD4, a and STK11 C

Hereditary neuroendocrine tumor 81437 y disorders (eg, medullary thyroid r carcinoma, parathyroid carcinoma, a t malignant pheochromocytoma or i

paraganglioma); genomic sequence d

analysis panel, must include sequencing e of at least 6 genes, including MAX, SDHB, r SDHC, SDHD, TMEM127, and VHL e H

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Procedures addressed by this Procedure codes guideline Hereditary neuroendocrine tumor 81438 disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); duplication/deletion analysis panel, must include analyses for

SDHB, SDHC, SDHD, and VHL s l

BreastNext, Ambry Genetics, Ambry 0102U e

Genetics n CancerNext, Ambry Genetics, Ambry 0104U a P

Genetics

ColoNext, Ambry Genetics, Ambry 0101U e Genetics n e OvaNext, Ambry Genetics, Ambry 0103U g

Genetics i t Miscellaneous hereditary cancer 81400 l syndrome gene tests u M

Miscellaneous hereditary cancer 81401 syndrome gene tests e

Miscellaneous hereditary cancer 81402 m

syndrome gene tests o r Miscellaneous hereditary cancer 81403 syndrome gene tests d n

Miscellaneous hereditary cancer 81404 y

syndrome gene tests S

Miscellaneous hereditary cancer 81405 r syndrome gene tests e Miscellaneous hereditary cancer 81406 c syndrome gene tests n a Miscellaneous hereditary cancer 81407 C syndrome gene tests y

Miscellaneous hereditary cancer 81408 r syndrome gene tests a t Miscellaneous hereditary cancer 81479 i syndrome gene tests d e r e H

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What are hereditary cancer syndromes

Definition

A hereditary cancer syndrome is when a mutation in a single gene causes a significantly increased risk for certain cancers. Hereditary cancer syndromes are usually characterized by a pattern of specific cancer types occurring together in the same family, younger ages of cancer diagnosis than usual, or other co-existing non- cancer conditions.

Prevalence

Most cancer is sporadic and believed to be caused by a mix of behavioral or lifestyle, environmental, and inherited risk factors. However, about 5-10% of cancers are believed to have a major inherited component.1

Hereditary cancer syndromes

There are at least 50 hereditary cancer syndromes.1 This table lists some of the most common along with associated cancers.2

Syndrome Associated cancers Hereditary breast and ovarian cancer • breast syndrome (HBOC) • ovarian, fallopian tube, or primary e

peritoneal cancer m

• pancreatic o r

• prostate d n

Lynch syndrome • colorectal y S

• endometrial r

• small bowel e • stomach c n

• ovarian a C

• pancreatic

• ureteral and renal pelvis y r

• biliary tract a t i • brain d

• sebaceous adenoma e r

• keratoacanthoma tumors e H

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Syndrome Associated cancers Familial adenomatous polyposis • colorectal and other gastrointestinal cancers • gastrointestinal tract polyps such as adenomas and fundic gland • osteomas • desmoids • thyroid cancer • hepatoblastoma

MUTYH-associated polyposis • colorectal and other gastrointestinal cancers • adenomas • hyperplastic polyps

Cowden syndrome • benign and malignant tumors of the breast, endometrium, and thyroid • cancer and polyps (hamartomas) in e the colon and rectum m

Li Fraumeni syndrome o

• soft tissue sarcoma r

• osteosarcoma d n • leukemia y

• melanoma S

• breast r e

• pancreas c

• colon n a • adrenal cortex C

• stomach y • esophagus r a t

• brain i d e r e H

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Syndrome Associated cancers Peutz-Jeghers syndrome • polyps (hamartomas) in the stomach • small intestine and colon • pancreas • lung • breast • uterine • ovarian

Overlapping clinical findings Many hereditary cancer syndromes can include the same types of cancer and therefore have overlapping clinical findings. For example, breast cancer is a feature of HBOC caused by BRCA mutations, Li Fraumeni syndrome, Cowden syndrome, and others. Sometimes, the pattern of cancers in the family or pathognomonic features makes the underlying syndrome clear. However, in many cases it can be difficult to reliably diagnose hereditary cancer syndromes based on clinical and family history alone. e

Test information m o

Introduction r d

Testing for hereditary cancer syndromes may include multigene panel testing. n y Sanger Sequencing S

Until recently, most sequencing tests used the Sanger sequencing methodology that r was originally developed in the 1970s. Sanger sequencing is labor intensive and did e not lend itself to high-throughput applications. c n

Next-generation sequencing (NGS) a C NGS, which is also sometimes called massively parallel sequencing, has been y

developing since about 2005 to allow larger scale and more efficient gene sequencing. r

NGS relies on sequencing many copies of small pieces of DNA simultaneously and a t using bioinformatics to assemble the sequence. i

The efficiency of NGS has led to an increasing number of large, multi-gene testing d panels. NGS panels that test several genes at once are particularly well-suited to e r

conditions caused by more than one gene or where there is considerable clinical e overlap between conditions making it difficult to reliably narrow down likely causes. As H

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a result, several laboratories have begun to combine genes involved in causing various hereditary cancer syndromes, which often have both of those characteristics.

Detection rate of NGS NGS may not perform as well as Sanger sequencing in some applications. Results may also be obtained that cannot be adequately interpreted based on the current knowledgebase.

o When a sequence variation is identified that has not been previously characterized or shown to cause the disorder in question, it is called a variant of uncertain significance (VUS). VUSs are relatively common findings when sequencing large amounts of DNA with NGS. o Under certain circumstances, technologies used in multi-gene testing may fail to identify mutations that might be identifiable through single-gene testing. If high clinical suspicion remains for a particular syndrome after negative multi-gene test results, consultation with the testing lab, additional targeted genetic testing, or both may be warranted.

Hereditary cancer syndrome multi-gene panels

Hereditary cancer syndrome multi-gene panels include a wide variety of genes and may be focused on the genetic causes of a particular cancer type or broad detection of common hereditary cancer syndromes. e Multi-gene tests vary in technical specifications. For example, different labs may have different depth of coverage, extent of Intron/Exon Boundary analysis, or methodology m o

of large Deletion/Duplication Analysis. r

Because genes can be easily added or removed from multi-gene tests over time by a d given lab, medical records must document n y

 the genes included in the specific multi-gene test used from each patient, and S

 the labs that performed the panels. r e

Moderate risk genes c n

Panels may also include genes believed to be associated with cancer, but with a a more modest impact on risk than recognized hereditary cancer syndromes. Results C for such genes are of less clear value because there often are not clear management recommendation for mutation-positive individuals. y r a t i d e r e H

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Guidelines and evidence

Introduction

This section includes relevant guidelines and evidence pertaining to herditary cancer syndrome panel testing.

National Comprehensive Cancer Network (NCCN)

The National Comprehensive Cancer Network (NCCN) makes the following general recommendations for using multi-gene panels in evaluating risk for breast and ovarian cancer and now includes this option in some management algorithms:3 ,4 “Because of their complexity, multi-gene testing is ideally offered in the context of professional genetic expertise for pre- and post-test counseling.” “Testing of an individual without a cancer diagnosis should only be considered when an appropriate affected family member is unavailable for testing.” “When more than one gene can explain an inherited cancer syndrome, then multi-gene testing may be more efficient and/or cost effective. As commercially available tests differ in the specific genes analyzed (as well as classification of variants and many other factors), choosing the specific laboratory and test panel is important. Multi-gene testing can include ‘intermediate’ penetrant (moderate-risk) genes. For many of these genes, there is limited data on the degree of cancer risk and there are no clear guidelines on risk management for carriers of mutations. Not all genes included on e available multi-gene tests are necessarily clinically actionable.” If a moderate risk gene mutation is identified, “gene carriers should be encouraged to participate in clinical m o

trials or genetic registries.” r

“Mutations in many breast cancer susceptibility genes involved in DNA repair may be d associated with the rare autosomal recessive condition, Fanconi anemia.” Therefore, n multi-gene testing may unexpectedly reveal that an individual and their family are at an y increased risk for this condition. S

“There is an increased likelihood of finding variants of unknown significance when r testing for mutations in multiple genes.” e c

American College of Medical Genetics n a

The American College of Medical Genetics has a policy statement that offers general C guidance on the clinical application of large-scale sequencing focusing primarily on y

whole exome and whole genome testing. However, some of the recommendations r

regarding counseling around unexpected results, variants of unknown significance, and a

5 t minimum requirements for reporting apply to many NGS applications. i d e r e H

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Criteria

Introduction

Requests for hereditary cancer syndrome panel testing are reviewed using these criteria.

Criteria

This guideline applies to all hereditary cancer syndrome panels, which are defined as assays that simultaneously test for more than one hereditary cancer syndrome. This guideline does not apply when testing more than one gene related to the same hereditary cancer syndrome (e.g., Lynch syndrome). Medical necessity coverage generally relies on criteria established for testing individual hereditary cancer syndromes. See the Coverage Guidance table for examples of genes known to be included in currently available hereditary cancer syndrome multi- gene panels with coverage guidance. This is not intended to be a complete list of available genes as these panels are evolving rapidly. However, this guideline takes into account the efficiency gains from simultaneously testing multiple candidate genes. Therefore, coverage requirements rely to some degree on how the panel will be billed. Panels may be billed in a variety of ways:  Gene sequencing portion: e o A separate CPT code for sequencing each gene studied or a subset (e.g., 81201, 81294, 81297, etc.) m o

o A single CPT code developed specifically for a particular type of panel (e.g., r 81432, 81435, 81437) d n o A single unlisted CPT code (e.g., 81479) y S

 Deletion/duplication analysis portion: r

o A separate CPT code for deletion/duplication analysis of each gene studied or a e subset (e.g., 81203, 81292, 81294, 81404, 81479, etc.) c n A single CPT code developed specifically for a particular type of panel (e.g.,

o a 81433, 81436, 81438) C o Microarray analysis (e.g., 81228 or 81229) y

o Part of a single unlisted CPT code for the sequencing and deletion/duplication r a

portions of the panel (e.g., 81479) t i

Hereditary cancer syndrome multi-gene panels will be reimbursed when the following d criteria are met: e r e H

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 Panel will be billed with separate procedure codes for each gene analyzed (however, please note that the billed amount should not exceed the list price of the test). o The medical necessity of each billed procedure will be assessed independently. See the Coverage Guidance table for gene-specific policy guidance. . When a patient meets medical necessity criteria for any hereditary cancer syndrome gene(s) included in a multi-gene panel, genetic testing for the clinically indicated gene(s) will be reimbursed. This includes the sequencing and deletion/duplication† components. . Any genes that are included in a multi-gene panel but do NOT meet medical necessity criteria will NOT be reimbursed. It will be at the laboratory, provider, and patient’s discretion to determine if a multi-gene panel remains the preferred testing option.

o Sequencing and/or deletion/duplication analysis† of any hereditary cancer syndrome gene(s) should only be performed once per lifetime and will therefore only be reimbursed once per lifetime. If gene testing was previously performed, and is now being included in a panel, such testing will not be separately reimbursable regardless of whether clinical coverage criteria are met, OR  Panel will be billed with a single procedure code to represent all genes being sequenced, with or without another single procedure code representing the deletion/duplication analysis† portion. Code(s) may be specific to that panel or an e

unlisted code, such as 81479. m o

o No previous hereditary cancer syndrome testing has been performed r d . Medical necessity must be established for at least two conditions included in n

the panel (e.g., hereditary breast and ovarian cancer and Li Fraumeni y syndrome). Note that this is two conditions and not two genes (i.e., meeting S

criteria for only Lynch syndrome, which is caused by mutations in at least 5 genes, would not fulfill criteria alone). r e

Although not a complete list, the following are considered separate c

conditions: n

 Hereditary breast cancer - this includes both BRCA1/2 and PALB2. a C

 Lynch syndrome

 Li-Fraumeni y r

 Familial adenomatous polyposis a t i  Cowden syndrome d e

o Testing for one condition was performed and billed separately. A multi-gene r

panel is now being considered as a reflex and will be billed at a rate comparable e to single syndrome pricing (e.g., myRisk update). H

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. Medical necessity must be established for at least one condition included in the panel in addition to the already tested condition (e.g., hereditary breast and ovarian cancer was already performed, but Lynch syndrome criteria are also met). . Note that if BRCA1/2 testing was already performed and PALB2 criteria are now met, PALB2 testing alone would be reimbursable and not a reflex panel test (e.g. myRisk Update). † When deletion/duplication testing is not part of a single panel CPT code being billed, deletion/duplication testing should be billed in only one of the following ways:  A separate CPT code for deletion/duplication analysis of each individual gene (may include non-specific molecular pathology tier 2 codes or unlisted code 81479), or  A single CPT code specific to the performed deletion/duplication analysis panel, or  A single microarray procedure

Procedure codes representing multiple methods for deletion/duplication testing will not be reimbursable for the same panel (e.g., test-specific deletion/duplication procedure codes and microarray will not both be reimbursable for the same panel).

Coverage guidance

The following table describes coverage guidance for genes associated with hereditary cancer syndromes. e

Coverage Guidance for Genes Included in Hereditary Cancer Syndrome Multi-Gene m Panels o r

Condition Test Name CPT Claim Code Reimbursemen d t n y

Birt-Hogg-Dube FLCN 81479 FLCNSEQ MOL.CU.109 S syndrome Sequencing r

FLCN 81479 FLCNDD MOL.CU.109 e

Deletion/Duplic c

ation Analysis n Cowden PTEN 81323 NONE MOL.TS.223 a C

syndrome, Deletion/Duplic

PTEN ation Analysis y hamartoma PTEN 81321 NONE MOL.TS.223 r tumor syndrome a Sequencing t i

Cutaneous CDK4 81479 CDK4DD MOL.TS.170 d

malignant Deletion/Duplic e melanoma ation Analysis r e H

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Condition Test Name CPT Claim Code Reimbursemen t CDK4 Exon 2 81479 CDK4EX2 MOL.TS.170 Sequencing CDKN2A 81479 CDKN2A MOL.TS.170 Deletion/Duplic ation Analysis CDKN2A 81404 CDKN2A MOL.TS.170 Sequencing Familial APC 81203 NONE MOL.TS.168 adenomatous Deletion/Duplic polyposis ation Analysis APC 81201 NONE MOL.TS.168 Sequencing Familial breast AKT1 81479 AKT1DD Not reimbursed and/or ovarian Deletion/Duplic cancer ation Analysis AKT1 81479 AKT1SEQ Not reimbursed Sequencing ATM 81479 ATM Not reimbursed Deletion/Duplic e

ation Analysis m

ATM 81408 ATM Not reimbursed o r Sequencing d

BARD1 81479 BARD1DD Not reimbursed n

Deletion/Duplic y

ation Analysis S

BARD1 81479 BARD1SEQ Not reimbursed r

Sequencing e BRIP1 81479 BRIP1DD Not reimbursed c Deletion/Duplic n ation Analysis a C BRIP1 81479 BRIP1 Not reimbursed Sequencing y r

CHEK2 81479 CHEK2DD Not reimbursed a t

Deletion/Duplic i

ation Analysis d

CHEK2 81479 CHEK2SEQ Not reimbursed e r

Sequencing e H

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Condition Test Name CPT Claim Code Reimbursemen t FAM175A 81479 FAM175ADD Not reimbursed Deletion/Duplic ation Analysis FAM175A 81479 FAM175ASEQ Not reimbursed Sequencing GEN1 81479 GEN1DD Not reimbursed Deletion/Duplic ation Analysis GEN1 81479 GEN1SEQ Not reimbursed Sequencing MRE11A 81479 MRE11ADD Not reimbursed Deletion/Duplic ation Analysis MRE11A 81479 MRE11ASEQ Not reimbursed Sequencing NBN 81479 NBNDD Not reimbursed Deletion/Duplic ation Analysis NBN 81479 NBNSEQ Not reimbursed e

Sequencing m

RAD50 81479 RAD50DD Not reimbursed o r Deletion/Duplic ation Analysis d n

RAD50 81479 RAD50SEQ Not reimbursed y

Sequencing S

RAD51 81479 RAD51DD Not reimbursed r

Deletion/Duplic e

ation Analysis c RAD51 81479 RAD51SEQ Not reimbursed n Sequencing a C RAD51C 81479 RAD51CDD Not reimbursed Deletion/Duplic y ation Analysis r a t

RAD51C 81479 RAD51CSEQ Not reimbursed i

Sequencing d

RAD51D 81479 RAD51DDD Not reimbursed e r

Deletion/Duplic e ation Analysis H

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Condition Test Name CPT Claim Code Reimbursemen t RAD51D 81479 RAD51DSEQ Not reimbursed Sequencing SMARCA4 81479 SMARCA4DD Not reimbursed Deletion/Duplic ation Analysis SMARCA4 81479 SMARCA4SEQ Not reimbursed Sequencing XRCC2 81479 XRCC2DD Not reimbursed Deletion/Duplic ation Analysis XRCC2 81479 XRCC2SEQ Not reimbursed Sequencing XRCC3 81479 XRCC3DD Not reimbursed Deletion/Duplic ation Analysis XRCC3 81479 XRCC3SEQ Not reimbursed Sequencing Familial AXIN2 81479 AXIN2DD Not reimbursed colorectal Deletion/Duplic e

cancer ation Analysis m

AXIN2 81479 AXIN2SEQ Not reimbursed o r Sequencing d

GALNT12 81479 GALNT12DD Not reimbursed n

Deletion/Duplic y

ation Analysis S

GALNT12 81479 GALNT12SEQ Not reimbursed r

Sequencing e MLH3 81479 MLH3DD Not reimbursed c Deletion/Duplic n ation Analysis a C MLH3 81479 MLH3SEQ Not reimbursed Sequencing y r

POLE 81479 POLESEQ Not reimbursed a t

Sequencing i

POLD1 81479 POLD1SEQ Not reimbursed d Sequencing e r e H

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Condition Test Name CPT Claim Code Reimbursemen t Familial ATR 81479 ATRDD Not reimbursed cutaneous Deletion/Duplic telangiectasia ation Analysis and cancer ATR 81479 ATRSEQ Not reimbursed syndrome Sequencing Familial PRSS1 81479 PRSS1 Not reimbursed pancreatic Deletion/Duplic cancer ation Analysis PRSS1 81404 PRSS1 Not reimbursed Sequencing Familial HOXB13 81479 HOXB13DD Not reimbursed prostate cancer Deletion/Duplic ation Analysis HOXB13 81479 HOXB13SEQ Not reimbursed Sequencing Familial renal MITF 81479 MITFSEQ Not reimbursed cell carcinoma Sequencing MITF 81479 MITFDD Not reimbursed Deletion/Duplic e

ation Analysis m

Familial Wilms WT1 81405 WT1 MOL.CU.109 o r tumor Sequencing d

Hereditary BRCA1/2 81163 NONE MOL.TS.238 n

breast and Sequencing y

ovarian cancer S

BRCA1/2 81164 NONE MOL.TS.238

Deletion/Duplic r

ation Analysis e BRCA1 81165 NONE MOL.TS.238 c Sequencing n a BRCA1 81166 NONE MOL.TS.238 C Deletion/Duplic ation Analysis y r

BRCA2 81216 NONE MOL.TS.238 a t

Sequencing i

BRCA2 81167 NONE MOL.TS.238 d Deletion/Duplic e r

ation Analysis e H

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Condition Test Name CPT Claim Code Reimbursemen t Hereditary PALB2 81406 PALB2 MOL.TS.251 breast and Sequencing pancreatic cancer Hereditary CDH1 81406 CDH1 MOL.CU.109 diffuse gastric Sequencing cancer CTNNA1 81479 CTNNA1DD MOL.CU.109 Deletion/Duplic ation Analysis CTNNA1 81479 CTNNA1SEQ MOL.CU.109 Sequencing Hereditary FH Sequencing 81405 FH MOL.CU.109 leiomyomatosis with renal cell cancer Hereditary GREM1 81479 GREM1DD Not reimbursed mixed polyposis Deletion/Duplic syndrome ation Analysis

GREM1 81479 GREM1SEQ Not reimbursed e Sequencing m

Hereditary BMPR1A 81479 BMPR1ADD MOL.CU.109 o mixed polyposis Deletion/Duplic r syndrome, ation Analysis d Juvenile BMPR1A 81479 BMPR1ASEQ MOL.CU.109 n polyposis Sequencing y syndrome S

Hereditary MET 81479 METSEQ MOL.CU.109 r papillary renal Sequencing e c cell carcinoma MET 81479 METDD MOL.CU.109 n Deletion/Duplic a ation Analysis C Hereditary SDHA 81406 SDHA MOL.CU.109 paraganglioma- Sequencing y r pheochromocyt SDHB 81479 SDHB MOL.CU.109 a oma syndromes t Deletion/Duplic i

ation Analysis d e

SDHB 81405 SDHB MOL.CU.109 r

Sequencing e H

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Condition Test Name CPT Claim Code Reimbursemen t SDHC 81404 SDHC MOL.CU.109 Deletion/Duplic ation Analysis SDHC 81405 SDHC MOL.CU.109 Sequencing SDHD 81479 SDHD MOL.CU.109 Deletion/Duplic ation Analysis SDHD 81404 SDHD MOL.CU.109 Sequencing MAX 81479 MAXSEQ MOL.CU.109 Sequencing MAX 81479 MAXDD MOL.CU.109 Deletion/Duplic ation Analysis SDHAF2 81479 SDHAF2SEQ MOL.CU.109 Sequencing SDHAF2 81479 SDHAF2DD MOL.CU.109 Deletion/Duplic e

ation Analysis m

TMEM127 81479 TMEM127SEQ MOL.CU.109 o r Sequencing d

TMEM127 81479 TMEM127DD MOL.CU.109 n

Deletion/Duplic y

ation Analysis S

Juvenile SMAD4 81405 SMAD4 MOL.CU.109 r polyposis Deletion/Duplic e syndrome ation Analysis c SMAD4 81406 SMAD4 MOL.CU.109 n Sequencing a C Li-Fraumeni TP53 81479 TP53 MOL.TS.193 syndrome Deletion/Duplic y ation Analysis r a t

TP53 81405 TP53 MOL.TS.193 i

Sequencing d

TP53 Targeted 81404 TP53 MOL.TS.193 e r

Sequencing e H

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Condition Test Name CPT Claim Code Reimbursemen t Lynch EPCAM 81403 EPCAM MOL.TS.197 syndrome Deletion/Duplic ation Analysis MLH1 81294 NONE MOL.TS.197 Deletion/Duplic ation Analysis MLH1 81292 NONE MOL.TS.197 Sequencing MSH2 81297 NONE MOL.TS.197 Deletion/Duplic ation Analysis MSH2 81295 NONE MOL.TS.197 Sequencing MSH6 81300 NONE MOL.TS.197 Deletion/Duplic ation Analysis MSH6 81298 NONE MOL.TS.197 Sequencing PMS2 81319 NONE MOL.TS.197 e

Deletion/Duplic m

ation Analysis o r PMS2 81317 NONE MOL.TS.197 Sequencing d n

Multiple MEN1 81404 MEN1 MOL.CU.109 y

endocrine Deletion/Duplic S neoplasia type ation Analysis r 1 MEN1 81405 MEN1 MOL.CU.109 e

Sequencing c Multiple RET 81406 RET MOL.CU.109 n endocrine Sequencing a C neoplasia, type RET Targeted 81405 RET MOL.CU.109 2A Sequencing y r

MUTYH- MUTYH 81479 MUTYH MOL.TS.206 a t associated Deletion/Duplic i

polyposis ation Analysis d

MUTYH 81406 MUTYH MOL.TS.206 e r

Sequencing e H

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Condition Test Name CPT Claim Code Reimbursemen t Neurofibromato NF1 81479 NF1 MOL.CU.109 sis type 1 Deletion/Duplic ation Analysis NF1 81408 NF1 MOL.CU.109 Sequencing Peutz-Jeghers STK11 81404 STK11 MOL.TS.216 syndrome Deletion/Duplic ation Analysis STK11 81405 STK11 MOL.TS.216 Sequencing Tumor BAP1 81479 BAP1DD Not reimbursed predisposition Deletion/Duplic syndrome ation Analysis BAP1 81479 BAP1SEQ Not reimbursed Sequencing Unknown CHEK1 81479 CHEK1DD Not reimbursed phenotype Deletion/Duplic ation Analysis CHEK1 81479 CHEK1SEQ Not reimbursed e

Sequencing m

RAD51B 81479 RAD51BDD Not reimbursed o r Deletion/Duplic ation Analysis d n

RAD51B 81479 RAD51BSEQ Not reimbursed y

Sequencing S

von Hippel- VHL 81403 VHL MOL.TS.233 r

Lindau Deletion/Duplic e syndrome ation Analysis c VHL 81404 VHL MOL.TS.233 n Sequencing a C

Not reimbursed y r

Gene testing is not reimbursed strictly for hereditary cancer indications. In general, a t

this category applies to genes that have only a low to moderate impact on cancer i

risk (compared to high penetrance cancer syndrome-causing genes) and no clear d

management guidelines associated with identifying a mutation. e r e H

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References

Introduction

These references are cited in this guideline.

1. National Cancer Institute. Fact Sheets: Genetic Testing for Hereditary Cancer Syndromes (Reviewed April 11, 2013). Available at: http://www.cancer.gov/about- cancer/causes-prevention/genetics/genetic-testing-fact-sheet 2. Hampel H et al. A practice guideline from the American College of Medical Genetics and Genomics and the National Society of Genetic Counselors: referral indications for cancer predisposition assessment. Gen et Med. 2015; 17(1):70-87. Available at: https://www.acmg.net/docs/gim2014147a.pdf 3. National Comprehensive Cancer Network. Genetic/Familial High-Risk Assessment: Breast and Ovarian. Version 1.2018. Available at: http://www.nccn.org/professionals/physician_gls/pdf/genetics_screening.pdf 4. National Comprehensive Cancer Network. Genetic/Familial High-Risk Assessment: Colorectal. Version 1.2016. Available at: https://www.nccn.org/professionals/physician_gls/pdf/genetics_colon.pdf 5. ACMG Board of Directors. Points to consider in the clinical application of genomic sequencing. Genet Med. 2012 Aug;14(8):759-61. e m o r d n y S

r e c n a C

y r a t i d e r e H

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