Medical policy: Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)

Policy number: MP 2.211

Effective date: 3/1/2026

Policy

Genetic testing should be performed in a setting that has suitably trained health care providers who can give appropriate pre- and post-test counseling and that has access to a Clinical Laboratory Improvement Amendments-licensed laboratory that offers comprehensive variant analysis (see Policy Guidelines section: Comprehensive Variant Analysis).

Individuals with cancer or with a personal history of cancer

Genetic testing for BRCA1, BRCA2, and PALB2 variants in cancer-affected individuals may be considered medically necessary under any of the following circumstances:

• Individuals with any close blood relative with a known BRCA1, BRCA2, or PALB2 pathogenic/likely pathogenic variant (see Policy Guidelines for definitions and testing strategy).
• Individuals meeting the criteria below but with previous limited testing (e.g., single gene and/or absent deletion duplication analysis).
• Personal history of breast cancer and 1 or more of the following:
  • Diagnosed at age ≤45 years; or
  • Diagnosed at age 46 to 50 years with:
    • An additional breast cancer primary at any age; or
    • ≥1 close relative with breast, ovarian, pancreatic, or prostate cancer at any age; or
    • An unknown or limited family history.
  • Diagnosed at age ≤60 years with:
    • Triple-negative breast cancer (see Policy Guidelines).
  • Diagnosed at any age with:
    • ≥1 close blood relative with:
      • Breast cancer diagnosed at age ≤50 years; or
      • Ovarian carcinoma; or
      • Metastatic or intraductal/cribriform prostate cancer, or high-risk group or very-high-risk group (see Policy Guidelines) prostate cancer; or
      • Pancreatic cancer; or
    • ≥3 total diagnoses of breast cancer in individual and/or close blood relatives; or
    • Ashkenazi Jewish ancestry.
• Diagnosed at any age with male breast cancer.
• Personal history of epithelial ovarian carcinoma (including fallopian tube cancer or peritoneal cancer) at any age.
• Personal history of exocrine pancreatic cancer at any age.
• Personal history of metastatic or intraductal/cribriform histology prostate cancer at any age; or high-risk group or very-high-risk group prostate cancer at any age.
• Personal history of prostate cancer at any age with:
  • ≥1 close blood relative with ovarian carcinoma, pancreatic cancer, or metastatic or intraductal/cribriform prostate cancer at any age, or breast cancer at age ≤50 years; or
  • ≥2 close blood relatives with breast or prostate cancer (any grade) at any age; or
  • Ashkenazi Jewish ancestry.
• Personal history of a BRCA1, BRCA2, or PALB2 pathogenic/likely pathogenic variant identified on tumor genomic testing that has clinical implications if also identified in the germline.

Individuals without cancer or with other personal history of cancer

(See Policy Guidelines section: Testing Unaffected Individuals.)

Genetic testing for BRCA1, BRCA2, and PALB2 variants of cancer-unaffected individuals and individuals with cancer but not meeting the above criteria (including individuals with cancers unrelated to hereditary breast and ovarian cancer syndrome) may be considered medically necessary under any of the following circumstances:

• An individual without cancer and not meeting the above criteria but who has a 1st- or 2nd-degree blood relative meeting any criterion listed above for Patients with Cancer (except individuals who meet criteria only for systemic therapy decision-making). If the individual with cancer has pancreatic cancer or prostate cancer (metastatic or intraductal/cribriform or high-risk group or very-high-risk group), then only first-degree relatives should be offered testing unless there are other family history indications for testing.
• An individual with any type of cancer (cancer related to hereditary breast and ovarian cancer syndrome but not meeting above criteria, or cancer unrelated to hereditary breast and ovarian cancer syndrome) or unaffected individual who otherwise does not meet the criteria above but has a probability ≥5% of a BRCA1, BRCA2, or PALB2 pathogenic variant based on prior probability models (e.g., Tyrer-Cuzick, BRCAPro, PennII).

Genetic testing for BRCA1 and BRCA2 variants of cancer-affected individuals or cancer-unaffected individuals with a family history of cancer when criteria above are not met is considered investigational.

Testing for PALB2 variants in individuals who do not meet the criteria outlined above is considered investigational.

Genetic testing in minors for BRCA1, BRCA2, and PALB2 variants for hereditary breast and ovarian cancer syndrome is considered investigational (see Policy Guidelines).

Policy guidelines

There are differences in the position statements above and the National Comprehensive Cancer Network (NCCN) guideline on Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic (v.3.2024). Not all of the NCCN criteria are clearly separated for determining hereditary breast and ovarian cancer syndrome versus for guiding therapy. Testing for BRCA1, BRCA2, and/or PALB2 outside of the above criteria, such as testing all individuals with triple-negative breast cancer or testing all individuals diagnosed with breast cancer under the age of 50 years, may be indicated for guiding cancer therapies. Genetic testing for BRCA1 and BRCA2 variants in breast cancer-, pancreatic cancer-, prostate cancer-, or ovarian cancer-affected individuals who are considering systemic therapy is addressed separately in MP 2.392, MP 2.393, MP 2.394, and MP 2.395 respectively. Genetic testing for PALB2 variants in pancreatic cancer-affected individuals is also addressed in MP 2.392.

Additionally, conflicting criteria reflect that some of the NCCN criteria are based on limited or no evidence; the lower level of evidence might be needed when determining coverage of testing mandated by state biomarker legislation.

Current U.S. Preventive Services Task Force guidelines recommend screening women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with BRCA1/2 gene mutation. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing (B recommendation).

Recommended screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful variants in BRCA1 or BRCA2 are:

• Ontario Family History Assessment Tool (FHAT)
• Manchester Scoring System
• Referral Screening Tool (RST)
• Pedigree Assessment Tool (PAT)
• Family History Screen (FHS-7)
• International Breast Cancer Intervention Study instrument (Tyrer-Cuzick)
• Brief versions of the BRCAPRO

Close relatives

Close relatives are blood related family members including 1st-, 2nd-, and 3rd-degree relatives on the same side of the family (maternal or paternal).

• 1st-degree relatives are parents, siblings, and children.
• 2nd-degree relatives are grandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings.
• 3rd-degree relatives are great-grandparents, great-aunts, great-uncles, great-grandchildren, and first cousins.

Prostate cancer risk groups

Risk groups for prostate cancer in this policy include high-risk groups and very-high-risk groups.

High-risk group: no very-high-risk features and T3a (American Joint Committee on Cancer staging T3a = tumor has extended outside of the prostate but has not spread to the seminal vesicles); or Grade Group 4 or 5; or prostate specific antigen of 20 ng/mL or greater.

Very-high-risk group: T3b-T4 (tumor invades seminal vesicle(s); or tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall); OR Primary Gleason Pattern 5; OR 2 or 3 high-risk features; OR greater than 4 cores with Grade Group 4 or 5.

Recommended testing strategies

Individuals who meet criteria for genetic testing as outlined in the policy statements above should be tested for variants in BRCA1, BRCA2, and PALB2. Recommended strategies are listed below.

• In individuals with a known familial BRCA or PALB2 variant, targeted testing for the specific variant is recommended.
• In individuals with unknown familial BRCA or PALB2 variant:
  • To identify clinically significant variants, NCCN advises testing a relative who has early-onset disease, bilateral disease, or multiple primaries, because that individual has the highest likelihood of obtaining a positive test result. Unless the affected individual is a member of an ethnic group for which particular founder pathogenic or likely pathogenic variants are known, comprehensive genetic testing (i.e., full sequencing of the genes and detection of large gene rearrangements) should be performed.
  • If no living family member with breast or ovarian cancer exists, NCCN suggests testing first- or second-degree family members affected with cancer thought to be related to deleterious BRCA1 or BRCA2 variants (e.g., prostate cancer, pancreatic cancer, melanoma).
  • If no familial variant can be identified, 2 possible testing strategies are:
    • Full sequencing of BRCA1 and BRCA2 followed by testing for large genomic rearrangements (deletions, duplications) only if sequencing detects no variant (negative result).
    • Alternatively, simultaneous full sequencing and testing for large genomic rearrangements (also known as comprehensive BRCA testing; see Comprehensive Variant Analysis below) may be performed as is recommended by NCCN.
• Testing for BRCA1, BRCA2, and PALB2 through panel testing over serial testing might be preferred for efficiency. Multi-gene panels often include genes of moderate or low penetrance, and genes with limited evidence on which to base management decisions. When considering a gene panel, NCCN recommends use of “tailored panels that are disease-focused and include clinically actionable cancer susceptibility genes”.
• Ashkenazi Jewish descent:
  • In individuals of known Ashkenazi Jewish descent, one approach is to test for the 3 known founder mutations (185delAG and 5182insC in BRCA1; 6174delT in BRCA2) first; if testing is negative for founder mutations and if the individual’s ancestry also includes non-Ashkenazi ethnicity (or if other BRCA1/2 testing criteria are met), comprehensive genetic testing should be considered.

Testing strategy may also include testing individuals not meeting the above criteria who are adopted and have limited medical information on biological family members, individuals with small family structure, and individuals with presumed paternal transmission.

Comprehensive variant analysis

Comprehensive variant analysis currently includes sequencing the coding regions and intron and exon splice sites, as well as testing to detect large deletions and rearrangements that can be missed with sequence analysis alone. In addition, before August 2006, testing for large deletions and rearrangements was not performed; thus some individuals with familial breast cancer who had negative BRCA testing before this time may consider repeat testing for the rearrangements (see Policy section for criteria).

High-risk ethnic groups

Testing of eligible individuals who belong to ethnic populations in which there are well-characterized founder mutations should begin with tests specifically for these variants. For example, founder mutations account for approximately three-quarters of the BRCA variants found in Ashkenazi Jewish populations (see Rationale section). When testing for founder mutations is negative, a comprehensive variant analysis should then be performed.

Testing unaffected individuals

In unaffected family members of potential BRCA or PALB2 variant families, most test results will be negative and uninformative. Therefore, it is strongly recommended that an affected family member be tested first whenever possible to adequately interpret the test. Should a BRCA or PALB2 variant be found in an affected family member(s), DNA from an unaffected family member can be tested specifically for the same variant of the affected family member without having to sequence the entire gene.

Interpreting test results for an unaffected family member without knowing the genetic status of the family may be possible in the case of a positive result for an established disease-associated variant but leads to difficulties in interpreting negative test results (uninformative negative) or variants of uncertain significance because the possibility of a causative BRCA or PALB2 variant is not ruled out.

Testing for known variants of BRCA or PALB2 genes in an unaffected reproductive partner may be indicated as carrier screening for rare autosomal recessive conditions.

Confirmatory testing

Consideration might be given at the local level for confirmatory germline testing of a BRCA or PALB2 pathogenic/likely pathogenic variant found on tumor genomic analyses, direct-to-consumer testing, or research testing.

Testing minors

The use of genetic testing for BRCA1, BRCA2, or PALB2 variants for identifying hereditary breast and ovarian cancer syndrome has limited or no clinical utility in minors, because there is no change in management for minors as a result of knowledge of the presence or absence of a deleterious variant. In addition, there are potential harms related to stigmatization and discrimination. See policy MP 2.362 regarding testing of BRCA1, BRCA2, and PALB2 for Fanconi anemia. See policies 2.392, 2.393, 2.394, and 2.395 regarding genetic testing to guide targeted therapy.

Prostate cancer

Individuals with BRCA or PALB2 variants have an increased risk of prostate cancer, and individuals with known BRCA or PALB2 variants may, therefore, consider more aggressive screening approaches for prostate cancer.

Genetics nomenclature update

The Human Genome Variation Society nomenclature is used to report information on variants found in DNA and serves as an international standard in DNA diagnostics. It is being implemented for genetic testing medical evidence review updates starting in 2017 (see Table PG1). The Society’s nomenclature is recommended by the Human Variome Project, the Human Genome Organization, and by the Human Genome Variation Society itself.

The American College of Medical Genetics and Genomics and the Association for Molecular Pathology standards and guidelines for interpretation of sequence variants represent expert opinion from both organizations, in addition to the College of American Pathologists. These recommendations primarily apply to genetic tests used in clinical laboratories, including genotyping, single genes, panels, exomes, and genomes. Table PG2 shows the recommended standard terminology — “pathogenic,” “likely pathogenic,” “uncertain significance,” “likely benign,” and “benign” — to describe variants identified that cause Mendelian disorders.

Table PG1. Nomenclature to report on variants found in DNA

Table PG2. ACMG-AMP standards and guidelines for variant classification

ACMG: American College of Medical Genetics and Genomics; AMP: Association for Molecular Pathology.

Genetic counseling

Genetic counseling is primarily aimed at patients who are at risk for inherited disorders, and experts recommend formal genetic counseling in most cases when genetic testing for an inherited condition is considered. The interpretation of the results of genetic tests and the understanding of risk factors can be very difficult and complex. Therefore, genetic counseling will assist individuals in understanding the possible benefits and harms of genetic testing, including the possible impact of the information on the individual’s family. Genetic counseling may alter the utilization of genetic testing substantially and may reduce inappropriate testing. Genetic counseling should be performed by an individual with experience and expertise in genetic medicine and genetic testing methods.

Cross-references:

• MP 2.255 Genetic testing for PTEN hamartoma tumor syndrome
• MP 2.259 Expanded molecular panel testing of cancers to identify targeted therapies
• MP 2.267 Circulating tumor DNA and circulating tumor cells for cancer management (liquid biopsy)
• MP 2.279 Germline genetic testing for gene variants associated with breast cancer in individuals at high breast cancer risk (CHEK2, ATM, BARD1)
• MP 2.325 Genetic cancer susceptibility panels using next generation sequencing
• MP 2.326 General approach to genetic testing
• MP 2.377 Molecular testing for germline variants associated with ovarian cancer (BRIP1, RAD51C, RAD51D, NBN)
• MP 2.384 Germline genetic testing for hereditary diffuse gastric cancer (CDH1, CTNNA1)
• MP 2.392 Germline genetic testing for pancreatic cancer susceptibility genes (ATM, BRCA1, BRCA2, CDKN2A, EPCAM, MLH1, MSH2, MSH6, PALB2, PMS2, STK11, and TP53)
• MP 2.393 Germline and somatic biomarker testing (including liquid biopsy) for targeted treatment in breast cancer (BRCA1, BRCA2, PIK3CA, Ki-67, RET, BRAF, ESR1, NTRK)
• MP 2.394 Germline and somatic biomarker testing (including liquid biopsy) for targeted treatment in prostate cancer (BRCA1/2, homologous recombination repair gene alterations, NTRK gene fusion)
• MP 2.395 Germline and somatic biomarker testing (including liquid biopsy) for targeted treatment in ovarian cancer (BRCA1, BRCA2, homologous recombination deficiency, NTRK)
• MP 5.013 Genetic testing for Lynch syndrome and other inherited colon cancer syndromes

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to FEP Medical Policy Manual.

Description/Background

Hereditary breast and ovarian cancer syndrome

Several genetic syndromes with an autosomal dominant pattern of inheritance that features breast cancer have been identified. Of these, hereditary breast and ovarian cancer (HBOC) syndrome and some cases of hereditary site-specific breast cancer have common causative variants in BRCA (breast cancer susceptibility genes). Families suspected of having HBOC syndrome are characterized by an increased susceptibility to breast cancer occurring at a young age, bilateral breast cancer, male breast cancer, ovarian cancer at any age, as well as cancer of the fallopian tube and primary peritoneal cancer. Other cancers, such as prostate cancer, pancreatic cancer, gastrointestinal cancers, melanoma, and laryngeal cancer, occur more frequently in HBOC families. Hereditary site-specific breast cancer families are characterized by early-onset breast cancer with or without male cases, but without ovarian cancer. For this evidence review, Capital refers collectively to both as hereditary breast and/or ovarian cancer.

Germline variants in the BRCA1 and BRCA2 genes are responsible for the cancer susceptibility in most HBOC families, especially if ovarian cancer or male breast cancer are features. However, in site-specific cancer, BRCA variants are responsible only for a proportion of affected families. BRCA gene variants are inherited in an autosomal dominant fashion through maternal or paternal lineage. It is possible to test for abnormalities in BRCA1 and BRCA2 genes to identify the specific variant in cancer cases and to identify family members at increased cancer risk. Family members without existing cancer who are found to have BRCA variants can consider preventive interventions for reducing risk and mortality.

Evidence suggests that genetic services are not equitably applied. Chapman-Davis et al. (2021) found that non-Hispanic Whites and Asians were more likely to be referred for genetic services based solely on family history than were non-Hispanic Blacks and Hispanics. In addition, non-Hispanic Black patients and Hispanic patients were more likely to have advanced cancer when referred for genetic services than non-Hispanic Whites and Asians.

Clinical features suggestive of BRCA variant

Young age of onset of breast cancer, even in the absence of family history, is a risk factor for BRCA variants. Winchester (1996) estimated that hereditary breast cancer accounts for 36% to 85% of patients diagnosed before age 30 years. In several studies, BRCA variants were independently predicted by early age at onset, being present in 6% to 10% of breast cancer cases diagnosed at ages younger than various premenopausal age cutoffs (age range, 35 to 50 years). In cancer-prone families, the mean age of breast cancer diagnosis among women carrying BRCA1 or BRCA2 variants is in the 40s.

In the Ashkenazi Jewish population, Frank et al. (2002) reported that 13% of 248 cases with no known family history and diagnosed before 50 years of age had BRCA variants. In a similar study by Gershoni-Baruch et al. (2000), 31% of Ashkenazi Jewish women, unselected for family history, diagnosed with breast cancer at younger than 42 years of age had BRCA variants. Other studies have indicated that early age of breast cancer diagnosis is a significant predictor of BRCA variants in the absence of family history in this population.

As in the general population, a family history of breast or ovarian cancer, particularly early age of onset, is a significant risk factor for a BRCA variant in ethnic populations characterized by founder mutations. For example, in unaffected individuals of Ashkenazi Jewish descent, 12% to 31% will have a BRCA variant depending on the extent and nature of the family history. Several other studies have documented the significant influence of family history.

In patients with “triple-negative” breast cancer (i.e., negative for expression of estrogen, progesterone, and overexpression of human epidermal growth factor receptor 2 receptors), there is an increased prevalence of BRCA variants. Pathophysiologic research has suggested that the physiologic pathway for the development of triple-negative breast cancer is similar to that for BRCA-associated breast cancer. In 200 randomly selected patients with triple-negative breast cancer from a tertiary care center, Kandel et al. (2006) reported there was a greater than 3-fold increase in the expected rate of BRCA variants. BRCA1 variants were found in 39.1% of patients and BRCA2 variants in 8.7%. Young et al. (2009) studied 54 women with high-grade, triple-negative breast cancer with no family history of breast or ovarian cancer, representing a group that previously was not recommended for BRCA testing. Six BRCA variants (5 BRCA1, 1 BRCA2) were found, for a variant rate of 11%. Finally, Gonzalez-Angulo et al. (2011), in a study of 77 patients with triple-negative breast cancer, reported that 15 patients (19.5%) had BRCA variants (12 in BRCA1, 3 in BRCA2).

PALB2 gene

The PALB2 gene (partner and localizer of BRCA2) encodes for a protein first described in 2006. The gene is located at 16p12.2 (short [p] arm of chromosome 16 at position 12.2) and has 13 exons. PALB2 protein assists BRCA2 in DNA repair and tumor suppression. Heterozygous pathogenic PALB2 variants increase the risk of developing breast and pancreatic cancers; homozygous variants are found in Fanconi anemia. Fanconi anemia is a rare disorder, primarily affecting children, that causes bone marrow failure, birth defects, and increased risk of cancer. Most pathogenic PALB2 variants are truncating frameshift or stop codons and are found throughout the gene. Pathogenic PALB2 variants are uncommon in unselected populations and prevalence varies by ethnicity and family history.

For example, Antoniou et al. (2014) assumed a prevalence of 8 per 10,000 in the general population when modeling breast cancer risks. Variants are more prevalent in ethnic populations where founder mutations have persisted (e.g., Finns, French Canadians, Poles), while infrequently found in others (e.g., Ashkenazi Jews). In women with a family history of breast cancer, the prevalence of pathogenic PALB2 variants ranges between 0.9% and 3.9%, or substantially higher than in an unselected general population. Depending on population prevalence, PALB2 may be responsible for as much as 2.4% of hereditary breast cancers; and in populations with founder mutations cause 0.5% to 1% of all breast cancers.

Regulatory status

Clinical laboratories may develop and validate tests in-house and market them as a laboratory service; laboratory-developed tests must meet the general regulatory standards of the Clinical Laboratory Improvement Amendments. Genetic tests reviewed in this evidence review are available under the auspices of the Clinical Laboratory Improvement Amendments. Laboratories that offer laboratory-developed tests must be licensed by the Clinical Laboratory Improvement Amendments for high-complexity testing. To date, the U.S. Food and Drug Administration (FDA) has chosen not to require any regulatory review of this test.

Rationale

Summary of evidence

For individuals who have cancer or a personal or family cancer history and meet criteria suggesting a risk of hereditary breast and ovarian cancer (HBOC) syndrome who receive genetic testing for a BRCA1 or BRCA2 variant, the evidence includes a TEC assessment and studies of variant prevalence and cancer risk. Relevant outcomes are overall survival, disease-specific survival, test validity, and quality of life. The accuracy of variant testing has been shown to be high. Studies of lifetime risk of cancer for carriers of a BRCA variant have shown a risk as high as 85%. Knowledge of BRCA variant status in individuals at risk of a BRCA variant may impact health care decisions to reduce risk, including intensive surveillance, chemoprevention, and/or prophylactic intervention. In individuals with BRCA1 or BRCA2 variants, prophylactic mastectomy and oophorectomy have been found to significantly increase disease-specific survival and overall survival. Knowledge of BRCA variant status in individuals diagnosed with breast cancer may impact treatment decisions. A randomized controlled trial has reported that patients with human epidermal growth factor receptor 2-negative metastatic breast cancer and a BRCA variant experienced significantly longer progression-free survival with a targeted therapy versus standard therapy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with other high-risk cancers (e.g., cancers of the fallopian tube, pancreas, and prostate) who receive genetic testing for a BRCA1 or BRCA2 variant, the evidence includes studies of variant prevalence and cancer risk. Relevant outcomes are overall survival, disease-specific survival, test validity, and quality of life. The accuracy of variant testing has been shown to be high. Knowledge of BRCA variant status in individuals with other high-risk cancers can inform decisions regarding genetic counseling, chemotherapy, and enrollment in clinical trials. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with a risk of HBOC syndrome who receive genetic testing for a PALB2 variant, the evidence includes studies of clinical validity and studies of breast cancer risk, including a meta-analysis. Relevant outcomes are overall survival, disease-specific survival, and test validity. Evidence supporting clinical validity was obtained from numerous studies reporting relative risks and odds ratios. Study designs included family segregation, kin-cohort, family-based case-control, and population-based case-control. The number of pathogenic variants identified in studies varied from truncation to missense variants. The relative risk for breast cancer associated with a PALB2 variant ranged from 2.3 to 13.4, with the 2 family-based studies reporting the lowest value. Evidence of preventive interventions in women with PALB2 variants is indirect, relying on studies of high-risk women and BRCA carriers. These interventions include screening with magnetic resonance imaging, chemoprevention, and risk-reducing mastectomy. Given the penetrance of PALB2 variants, the outcomes following bilateral and contralateral risk-reducing mastectomy examined in women with a family history consistent with hereditary breast cancer (including BRCA1 and BRCA2 carriers) can be applied to women with PALB2 variants, with benefit-to-risk balance affected by penetrance. In women at high risk of hereditary breast cancer who would consider risk-reducing interventions, identifying a PALB2 variant provides a more precise estimated risk of developing breast cancer compared with family history alone and can offer women a more accurate understanding of the benefits and potential harms of any intervention. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Definitions

N/A

Disclaimer

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Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Non-covered:

Covered when medically necessary:

References

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