Prior Authorization and Appeals

Prior authorization is the step at which a recommended genetic test most often stops. It is administrative rather than clinical, which is precisely why it is worth doing well: a denial usually reflects missing documentation rather than a considered judgment that the test is unhelpful. Counselors who understand the sequence and the deadlines convert a large share of denials.

• Prior authorization means the payer must approve before the test is performed. Testing sent without a required authorization is frequently not covered at all, and the patient receives the full bill. Verifying whether authorization is required is a step, not an assumption.
• What a strong initial request contains: the specific test and CPT code, the clinical indication, personal and family history in enough detail to show criteria are met, the guideline criteria cited by name, and a statement of how the result will change management. Requests that simply state a diagnosis and a test name are the ones that get denied.
• Cite the payer's own policy. Major insurers publish medical policies for genetic testing. An argument built on the payer's published criteria is far stronger than one built on general clinical reasoning, because it removes the reviewer's discretion.
• Common denial reasons are predictable: the test is called investigational or experimental, criteria were not documented, the test is considered not medically necessary, a stepwise alternative was not tried first, or the laboratory is out of network. Each has a different counter.
• Levels of appeal escalate. A peer-to-peer review puts the ordering clinician on the phone with the payer's medical director and is often the fastest resolution. A formal written appeal follows, then a second-level internal appeal, and finally external review by an independent entity, which is a right under the Affordable Care Act for most plans.
• Deadlines are real and short. Appeal windows are commonly 30 to 180 days from the denial, and missing one forecloses the appeal entirely regardless of merit. Diary the date on the day the denial arrives.
• Expedited appeals exist where delay would jeopardize health, and prenatal cases with a decision window are the clearest example. Ask for expedited review explicitly.
• Self-funded employer plans are governed by ERISA rather than state insurance law, so state mandates for genetic testing coverage do not apply and the appeal path differs. Determining plan type early avoids arguing from a law that does not govern.
• Run the assistance track in parallel. An appeal may take months. A patient assistance program may resolve the same barrier in days. Pursuing both at once is usually right, and is covered in financial assistance for genetic services.

• A patient meeting NCCN criteria for hereditary cancer testing is denied for insufficient documentation. The counselor resubmits with a three-generation pedigree, the specific NCCN criterion met quoted verbatim, and the management change that would follow a positive result. The authorization is approved without an appeal ever being filed.
• Exome sequencing for a child with developmental delay is denied as investigational. The counselor requests a peer-to-peer, in which the ordering geneticist cites the ACMG recommendation for exome as a first-tier test and the roughly 30 to 40 percent diagnostic yield in this population. The denial is overturned on the call.
• A prenatal diagnostic test is denied with a standard 30-day review timeline, but the pregnancy is at 19 weeks and the decision window is closing. The counselor requests an expedited appeal on the grounds that the standard timeline would render the result useless, and receives a determination in 72 hours.
• A patient's employer plan denies testing and the counselor begins citing the state's genetic testing coverage mandate. The plan is self-funded and governed by ERISA, so the state mandate does not apply. Recognizing this early redirects the appeal to the plan's own criteria.