UnitedHealthcare® Commercial Medical Policy Whole Exome and Whole Genome Sequencing Policy Number: 2021T0589I Effective Date: January 1, 2021 Instructions for Use Table of Contents Page Related Commercial Policies Coverage Rationale ........................................................................... 1 • Chromosome Microarray Testing (Non-Oncology Documentation Requirements......................................................... 2 Conditions) Definitions ........................................................................................... 2 • Molecular Oncology Testing for Cancer Diagnosis, Applicable Codes .............................................................................. 3 Prognosis, and Treatment Decisions Description of Services ..................................................................... 4 • Preimplantation Genetic Testing Clinical Evidence ............................................................................... 4 U.S. Food and Drug Administration ..............................................22 Community Plan Policy References .......................................................................................22 • Whole Exome and Whole Genome Sequencing Policy History/Revision Information..............................................26 Medicare Advantage Coverage Summaries Instructions for Use .........................................................................27 • Genetic Testing • Laboratory Tests and Services Coverage Rationale Whole Exome Sequencing (WES) Whole Exome Sequencing (WES) is proven and medically necessary for the following: • Diagnosing or evaluating a genetic disorder when the results are expected to directly influence medical management and clinical outcomes and all of the following criteria are met: o Clinical presentation is nonspecific and does not fit a well-defined syndrome for which a specific or targeted gene test is available. If a specific genetic syndrome is suspected, a single gene or targeted gene panel should be performed prior to determining if WES is necessary; and o WES is ordered by a board-certified medical geneticist, neonatologist, neurologist, or developmental and behavioral pediatrician; and o One of the following: . Clinical and/or family history strongly suggest a genetic cause for which a specific clinical diagnosis cannot be made with any clinically available targeted genetic tests; or . There is a clinical diagnosis of a genetic condition that can be caused by multiple genes and WES is a more practical approach to identifying the underlying genetic cause than are individual tests of multiple genes; or . There is likely a genetic disorder and multiple targeted gene tests have failed to identify the underlying cause • Comparator (e.g., parents or siblings) WES for evaluating a genetic disorder when the above criteria have been met and WES is performed concurrently or has been previously performed on the individual Due to insufficient evidence of efficacy, WES is unproven and not medically necessary for all other indications, including but not limited to the following: • Evaluation of fetal demise • Molecular profiling of tumors for the diagnosis, prognosis or management of cancer • Preimplantation Genetic Testing (PGT) in embryos • Prenatal genetic diagnosis or screening • Screening and evaluating disorders in individuals when the above criteria are not met Whole Exome and Whole Genome Sequencing Page 1 of 27 UnitedHealthcare Commercial Medical Policy Effective 01/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. Whole Genome Sequencing (WGS) Whole Genome Sequencing (WGS) is not medically necessary for evaluating any genetic disorder due to the availability of clinically equivalent diagnostic tests. Documentation Requirements Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The documentation requirements outlined below are used to assess whether the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested. CPT Codes* Required Clinical Information Whole Exome and Whole Genome Sequencing 0012U Medical notes documenting all of the following: 0013U • Personal history of the condition, if applicable, including age at diagnosis 0014U • Complete family history (usually three-generation pedigree) relevant to condition being tested 0214U • Genetic testing results of family member, if applicable, and reason for testing 0215U • Ethnicity/ancestry (e.g., Ashkenazi Jewish), if reason for testing 81415 • Any prior genetic testing results 81416 • How clinical management will be impacted based on results of genetic testing 81417 • Genetic counseling (if available) *For code descriptions, see the Applicable Codes section. Definitions Comparator: A DNA sequence that is used to compare to the individual’s DNA sequence. This may be a parent or sibling of the individual, or non-cancerous tissue that is being compared to the individual’s tumor tissue (Thun et al., 2017). Medically Necessary: Health care services that are all of the following as determined by us or our designee: • In accordance with Generally Accepted Standards of Medical Practice. • Clinically appropriate, in terms of type, frequency, extent, service site and duration, and considered effective for your Sickness, Injury, Mental Illness, substance-related and addictive disorders, disease or its symptoms. • Not mainly for your convenience or that of your doctor or other health care provider. • Not more costly than an alternative drug, service(s), service site or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your Sickness, Injury, disease or symptoms. Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, relying primarily on controlled clinical trials, or, if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes. If no credible scientific evidence is available, then standards that are based on Physician specialty society recommendations or professional standards of care may be considered. We have the right to consult expert opinion in determining whether health care services are Medically Necessary. The decision to apply Physician specialty society recommendations, the choice of expert and the determination of when to use any such expert opinion, shall be determined by us (UnitedHealthcare Insurance Company Generic Certificate of Coverage 2018). Next Generation Sequencing (NGS): New sequencing techniques that can quickly analyze multiple sections of DNA at the same time. Older forms of sequencing could only analyze one section of DNA at once. Preimplantation Genetic Testing (PGT): A test performed to analyze the DNA from oocytes or embryos for human leukocyte antigen (HLA)-typing or for determining genetic abnormalities. These include: • PGT-A: For aneuploidy screening (formerly PGS) • PGT-M: For monogenic/single gene defects (formerly single-gene PGD) Whole Exome and Whole Genome Sequencing Page 2 of 27 UnitedHealthcare Commercial Medical Policy Effective 01/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. • PGT-SR: For chromosomal structural rearrangements (formerly chromosomal PGD) (Zegers-Hochschild et al., 2017) Variant of Unknown Significance (VUS): A variation in a genetic sequence that has an unknown association with disease. It may also be called an unclassified variant. Whole Exome Sequencing (WES): About 1% of a person’s DNA makes protein. These protein making sections are called exons. All the exons together are called the exome. WES is a DNA analysis technique that looks at all of the exons in a person at one time, rather than gene by gene (U.S. National Library of Medicine, What are whole exome sequencing and whole genome sequencing? 2020). Whole Genome Sequencing (WGS): WGS determines the sequence of all of the DNA in a person, which includes the protein making (coding) as well as non-coding DNA elements (U.S. National Library of Medicine, What are whole exome sequencing and whole genome sequencing? 2020). Applicable Codes The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply. CPT Code Description 0012U Germline disorders, gene rearrangement detection by whole genome next-generation sequencing, DNA, whole blood, report of specific gene rearrangement(s) 0013U Oncology (solid organ neoplasia), gene rearrangement detection by whole genome next-generation sequencing, DNA, fresh or frozen tissue or cells, report of specific gene rearrangement(s) 0014U Hematology (hematolymphoid neoplasia), gene rearrangement detection by whole genome next- generation sequencing, DNA, whole blood