RESUMO
Published evidence-based guidelines help healthcare providers identify appropriate individuals for BRCA1/2 genetic testing. Health plans often use these guidelines to help make coverage and reimbursement decisions. Humana, a major health plan, launched the Humana Genetic Guidance Program to further facilitate the appropriate use of genetic testing through education. AIM: Identify opportunities to improve medical appropriateness for BRCA1/2 test requests by providing genetic education to providers. MATERIALS & METHODS: BRCA1/2 insurance preauthorization requests submitted to the program were evaluated against guideline-based coverage criteria. RESULTS: In total, 22% of the requests did not meet criteria, and in approximately a quarter of those requests, the clinical history suggested testing for a different cancer syndrome or another affected relative. CONCLUSION: This report demonstrates the program's effectiveness and illustrates the need for additional provider education regarding genetic testing from a payer's perspective.
