Why Genetic Testing Still Gets Denied—and What You Can Do About It
Angela is a nurse. She knows her way around hospital systems and care pathways. But even she was caught off guard.
When her OB-GYN recommended genetic testing due to a family history of ovarian cancer, she didn’t flinch. She had watched her mother battle cancer. She didn’t want to wait around for symptoms. She wanted a head start.
Then the letter came:
“Denied. Not considered medically necessary.”
Angela stared at the page.
No explanation. No appeal info. Just “no.”
What made it worse?
The doctor agreed the test was essential.
The science backed it.
But the insurance policy didn’t.
She’s not alone.
⚠️ The Real Issue: The System Isn’t Built for What’s Coming
We’re living in a time where medicine can look at your DNA and help prevent illness before it ever shows up. That’s powerful. But the insurance system? Still stuck in the past. Built for one-size-fits-all medicine. Reactive care. Not prevention.
“We’re using cutting-edge tech in clinics—but coverage policies were written in the flip-phone era.”
— Dr. Eric Topol
đź› Practical Tips to Help You—and Your Patients—Win
This isn’t theory. It’s stuff that’s worked in real clinics, real practices, with real people.
1. Add Real-Life Details to the Chart
Insurance reviewers don’t know the full story unless you tell it. A note that says “early cancer in mother, age 38” carries more weight than “screening test ordered.”
2. Be Obsessive With Codes
Use the right ICD-10 and CPT combos. Missing or mismatched codes are one of the top reasons claims get kicked back. Crosswalk carefully. Use documentation to explain why it’s relevant.
3. Team Up With Genetic Counselors
They’re more than test experts—they know how to explain the “why” in terms insurers respond to. They also know which labs code properly.
“Genetic counselors are translators—between your clinic and the people who write the checks.”
— Dr. Susan Klugman, Montefiore Einstein
4. Appeal, and Don’t Be Polite About It
A lot of “no’s” turn into “yes” after appeals. But you have to bring receipts—medical necessity letters, prior studies, guideline references.
5. Choose Labs With Patient Support Programs
Some labs offer price caps or payment plans if insurance refuses to pay. Always ask. The patient may not.
6. Educate the Front Desk
Your admin team deals with patients first. Equip them to answer tough billing questions with confidence—and empathy.
7. Speak Up. Loudly.
This problem isn’t just about one claim. It’s about an entire industry falling behind the science. If we don’t say something, it won’t change.
đź’¬ What the Experts Are Saying
Dr. Eric Topol, cardiologist and author
“Innovation in diagnostics means nothing if coverage denies people access.”
Dr. Susan Klugman, geneticist at Montefiore
“We have tools that can save lives. But we’re fighting billing rules, not biology.”
Dr. Brent Fogel, neurologist at UCLA
“We regularly see denials on genetic tests that are clearly indicated. It’s system failure, not provider failure.”
🧠Quick FAQ
Q: Why are so many genetic tests still denied?
A: Many insurance companies use outdated definitions of what counts as “necessary.” If it doesn’t fit their narrow criteria, it gets flagged.
Q: Can appeals actually work?
A: Yes—especially when paired with strong documentation. Persistence matters.
Q: Is this just a U.S. thing?
A: Mostly. In many countries with national healthcare, genetic testing is part of standard care. Here, it’s still “optional.”
Q: Any way to help patients afford it if insurance won’t cover?
A: Ask labs about financial assistance. Some offer significant discounts or cap charges for uninsured or denied patients.
đź“š What’s New This Week
-
CMS Tightens Rules on Multi-Gene Panels
Recent updates from CMS may limit access to hereditary cancer testing for broader populations.
👉 See the CMS Summary -
AMA Reports Uptick in Denials for Precision Diagnostics
A new report shows a nearly 20% increase in first-time denials for genetic tests in the last year.
👉 Read the AMA Coverage -
NCCN Updates Genetic Testing Guidelines
The National Comprehensive Cancer Network is now recommending broader testing based on newer risk models.
👉 Check the Latest NCCN Guidelines
🔥 Final Thought
If a test can help someone avoid disease, shouldn’t that be the point?
We talk a lot about innovation in medicine. But access—real access—is what makes it matter. Without coverage, even the best science stays locked behind a gate.
Let’s stop pretending denial letters are just a paperwork issue. They’re a care issue. A safety issue. A life issue.
đź—Ł Call to Action: Be Part of the Solution
It’s time to stop working around the system and start working on it.
✅ Join the conversation
✅ Tell your story
✅ Educate others in your clinic, your network, your space
Start here.
Step up.
Be the change.
Let’s fix this—together.
#GeneticTesting #PrecisionMedicine #InsuranceDenials #FixTheSystem #PatientFirst #Genomics #CareAccess #NCCN #RealMedicine #HealthEquity #FutureOfCare #StartHere #TakeAction #BeTheChange #JoinTheMovement #DoctorVoices #HealthcareNeedsReform
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