Effective Jan. 1, 2025, UnitedHealthcare (UHC) will no longer provide coverage for multigene panel pharmacogenetic tests.
According to a policy bulletin issued by UHC on Nov. 1, “The use of pharmacogenetic multigene panels (five or more genes) for the evaluation of drug-metabolizer status is unproven and not medically necessary for any indication due to insufficient evidence of efficacy.” The noncoverage decision also applies to use of the PrismRA molecular signature test, which evaluates an individual’s likelihood of an inadequate response to anti-tumor necrosis factor therapies for rheumatoid arthritis.
Twenty-one proprietary lab analyses and two CPT codes (81418 and 81479) will be impacted by this noncoverage decision. The policy bulletin explains that existing clinical evidence does not support the use of multigene pharmacogenetic tests for psychiatric indications, cardiovascular disease, anthracyclines, pain management, or rheumatoid arthritis. Additionally, UHC states there is insufficient evidence to support use of the tests to guide individualized therapies for indications such as multimorbidity, polypharmacy, and cancer treatment.
This medical policy applies to UHC Commercial benefit plans and Individual Exchange benefit plans in all states except Colorado.
Source:
