Cigna to require counseling for some genetic tests

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A good requirement: Genetic counseling

Amanda Gammon
The news that Cigna will now require patients to receive genetic counseling prior to having genetic testing relating to hereditary breast and ovarian cancer, colon cancer, and long QT syndrome is exciting and welcome. Genetic counselors and medical geneticists are uniquely trained to analyze patient medical and family histories to assess risk for hereditary disease. In addition, they have extensive experience in helping patients navigate the medical and psychosocial impacts of hereditary conditions, including the effects that extend to patients' families.

Among nongenetics specialists, studies have shown significant variability in providers' genetics knowledge, the type of genetic test they would order, the interpretation of genetic test results, and the medical management recommendations they would provide based on the results (Genet. Med. 2011;13:148-54; J. Genet. Couns. 2013 22:90-100; Am. J. Gastroenterol. 2002;97:729-33). Requiring genetic counseling prior to genetic testing helps ensure that patients receive comprehensive genetics risk assessment, precision in testing and interpretation of test results, psychosocial support, and access to current management recommendations, in addition to the expertise of their referring physician.

Dr. Randall Burt
As evidenced by Dr. Finley's comments, the goal of Cigna's new policy is to improve patient care and engagement. As new genetic testing options have recently become available (i.e., next-generation sequencing panels, whole exome and genome sequencing), genetics expertise is increasingly needed to identify the most appropriate test for each patient. Cigna's policy has the potential to increase provider awareness of genetics services and form new partnerships. In addition to Cigna's contract with InformedDNA, many local genetics clinics have the availability to see urgent patients, which should reduce concerns about patient wait times for genetic testing. We are hopeful that more insurance companies will follow Cigna's lead and show their support for the genetic counseling process as a valuable and increasingly crucial service for patients at risk for hereditary disease.

Amanda Gammon is at the University of Utah School of Medicine, Huntsman Cancer Institute, Salt Lake City. She has no financial conflicts of interest. Dr. Randall Burt is professor of medicine at the Huntsman Cancer Institute. He serves as a consultant for Myriad Genetics.


The health insurer Cigna soon will require its members to receive genetic counseling before they can undergo genetic testing for certain hereditary conditions.

The new policy, which takes effect Sept. 16, will apply to tests for the breast and ovarian cancer genes BRCA1 and BRCA2; colorectal cancer genetic screening; and long QT syndrome genetic tests for hereditary cardiac risk. The requirement will impact Cigna customers whose health plans require preauthorization.


The health insurer Cigna soon will require its members to receive genetic counseling before they can undergo genetic testing for certain hereditary conditions.

Cigna members will be counseled by either a medical geneticist or a board-certified genetic counselor before the tests can be ordered by the physician. The process will be similar to the preauthorization used for other services, according to Dr. David Finley, national medical officer for enterprise affordability and policy for Cigna.

Final decisions on whether a genetic test will be covered will be made by a Cigna medical director, who will give "great weight" to the counselor’s recommendation, Dr. Finley said. Cigna plans to share that recommendation with the physician and is currently working out how to do so.

Cigna is the first large, national health insurer to make genetic counseling a requirement for the coverage of genetic testing, but some regional health plans have been experimenting with this approach.

Cigna officials see counseling as part of the evolving standard of care in genetic testing, Dr. Finley said. The aim of the new policy is to ensure that genetic testing meets generally accepted national criteria and to reduce inappropriate testing, he said.

"Many genetic tests are misunderstood by the individuals who are requesting them. Sometimes the tests are ordered by the doctor, and the individual does not meet nationally accepted testing criteria," Dr. Finley said. "We think that requiring genetic counseling will result in better informed individuals who will make better decisions regarding testing. It will also eliminate some unnecessary and potentially harmful testing, and will also help individuals become more educated and more involved in their health care decisions."

Dr. David Finley

The new policy is expected to have a minimal impact on physicians, Dr. Finley said. Physicians may be asked to help patients find a genetic counselor, though Cigna will list qualified counselors on its website and has contracted with InformedDNA to provide quick access to counselors.

The Cigna policy should actually make things easier for physicians, said David Nixon, the CEO of InformedDNA, because it will give them access to genetic specialists. "It’s just impossible for front-line physicians to keep up with the pace of change in genetics," he said.

As part of their service, InformedDNA counselors will review family history and then counsel patients during a 45-minute to 1-hour phone or online appointment. All appointments are scheduled within 10 days, Mr. Nixon said.

Aside from counseling, InformedDNA also will handle much of the added paperwork involved with testing. While the referring physician still orders the test, InformedDNA handles the administrative work associated with the test, Mr. Nixon said.

Cigna’s relationship with InformedDNA could provide much-needed resources for physicians who aren’t comfortable counseling patients on genetic testing on their own, said Dr. Howard P. Levy, assistant professor in the internal medicine and genetic medicine departments at Johns Hopkins University in Baltimore.

But the new policy also has the potential to add delays and costs to the genetic testing process, Dr. Levy said. For instance, what if a cardiologist who is well versed on long QT syndrome genetic tests counsels his patient, but they are then required to meet with a genetic counselor to review the same information? Dr. Levy said that scenario would just slow down the process for patients and duplicate services.

"In genetic testing, sometimes it’s useful to get other people’s perspectives and sometimes that’s not so necessary," said Dr. Levy.

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