The impact of discrepant payor policies from one lab benefits manager on patient access to genetic testing

Presenting Author: Marissa Russell, MS, LGC

Take home points: 

1. Health plans are increasingly contracting lab benefits managers (LBMs) to implement and maintain medical policies and perform prior-authorization reviews, with the goal to reduce unnecessary testing and lower costs. One LBM has a more restrictive medical policy when compared to accepted standards of care, such as NCCN.
2. This discrepancy between the accepted NCCN guidelines and a prominent LBM guideline adds unnecessary complexity for busy clinicians when assessing patients for medical necessity.
3. This study highlights that eligibility restrictions implemented by an LBM, without supporting evidence, significantly decreased access for individuals who would otherwise meet standard-of-care parameters for genetic testing for hereditary cancer.
4. We also show that these patients had pathogenic variant prevalences of ~7-9% in clinically actionable genes, well within the risk range considered eligible for genetic testing.