Understanding TRICARE Coverage of Genetic Testing

TRICARE only covers genetic testing that is intended to be confirmatory of a clinical diagnosis already suspected based on a TRICARE beneficiary’s symptoms. Routine genetic testing that does not influence a beneficiary’s medical management is excluded from TRICARE coverage.

TRICARE-covered genetic testing includes the following:

• Genetic counseling is covered when it precedes the actual diagnostic genetic testing.
• Diagnostic genetic testing is covered when medically proven and appropriate and when the test results will influence the individual’s medical management.

The following examples of diagnostic tests are covered by TRICARE (Note: this is not an all inclusive list):

• Chromosome analysis (to include karyotyping and/or high resolution chromosome analysis) in some cases of habitual abortion or infertility
• Testing for Marfan Syndrome and chromosome analysis (to include karyotyping and/or high resolution chromosome analysis) of children. Common indications for chromosome analysis in children to include ambiguity of external genitalia, small-for-gestational age infants, multiple anomalies and failure to thrive.
• Other medically necessary genetic diagnostic tests

Genetic testing needs prior authorization. You may confirm authorization requirements for specific codes by referring to the Prior Authorization List on the Provider Connection area of www.triwest.com. The referring physician should submit the authorization request to TriWest and should send genetic testing to network laboratories. If a specific laboratory is not requested by the referring physician, TriWest will identify an appropriate genetic testing lab. After TriWest has confirmed that a network laboratory can’t perform the requested services, a non-network laboratory may be approved.

LabCorp and Quest are network laboratories. In addition, you may refer to www.triwest.com, Find a Provider tab, to find other local, network outpatient laboratories.

• Providers may refer to www.labcorp.com/dos for information on genetic testing performed by LabCorp.
• Providers may refer to www.questdiagnostics.com/hcp/topics/genetictesting/genetictesting.html for information on genetic testing performed by Quest.

Genetic laboratories should review the Government No Pay Procedure Code List to ensure services may be covered benefits before services are provided. The list can be found at www.triwest.com or www.tricare.mil.

For additional information on genetic testing, please refer to the TRICARE Policy Manual, Chapter 6, Section 3.1 at www.tricare.mil.