Insurers’ Genetic Counseling Requirements Impede Testing, ACOG Says

With increasing availability and surging demand for multi-gene panel tests for hereditary cancer, insurers are expanding requirements for pre-test counseling by a 'genetics professional.' The American College of Obstetricians and Gynecologists (ACOG) says these requirements will markedly limit access to BRCA testing for hereditary breast and ovarian cancer, particularly for patients in non-urban areas. In a position statement released in mid-December, ACOG reiterates its claim that board-certified obstetrician-gynecologists (ob-gyns) remain appropriate and qualified providers for pre-test counseling.

"Ob-gyns around the country screen women for a variety of cancers every day," Mark DeFrancesco, M.D., ACOG's president, said in a statement. "Ob-gyns know how to discuss the risk of cancer with their patients, and women are accustomed to having these important conversations with their ob-gyns. We are dedicated to ensuring that our patients receive the care they need, when they need it, and by physicians they trust."

ACOG claims that historically the majority of BRCA testing has been ordered by ob-gyns and insurers' requirements are restricting the scope of practice of ob-gyns. The group says the 'genetics professional' requirement imposes "unnecessary" and "not medically indicated" barriers to timely care. Furthermore, ACOG says its othposition statement is aligned with the American Medical Association Policy (H- 460.902) "Opposition to Genetic Testing Restrictions Based on Specialty," which specifically opposes limiting the ordering of genetic testing based solely on physician specialty and opposes requirements for utilization of non-affiliated medical specialists or non-physicians prior to ordering genetic testing.

"ACOG reaffirms its position that ob-gyns are fully trained and qualified to counsel patients regarding genetic issues specific to pregnancy and women's health- associated cancers, and that the ordering of genetic testing should not be restricted by a requirement for pre-testing genetic counseling by a separate provider," the position statement says.

These pre-test counseling requirements and pre-authorizations are part of a trend among large insurers. National Intelligence Report sampled policies and found:

• As of Jan. 1, United Healthcare requires genetic counseling by an independent genetics provider (not employed by a testing lab) prior to BRCA mutation testing. The policy notes, however, a physician "with experience in cancer genetics" (defined as having received specialized, ongoing training in cancer genetics) can document medical necessity and provide test-related counseling.
• In 2015, the Centers for Medicare & Medicaid Services issued a draft local coverage determination proposing that pretest genetic counseling by a cancer genetics professional would be required for patients undergoing multi-gene panel testing.
• Cigna requires precertification for all BRCA tests and dating back to 2013 requires pre-testing genetic counseling from an independent board-certified genetic counselor or clinical geneticist for hereditary conditions, including breast and ovarian cancer, colorectal cancer syndromes, and Long QT syndrome.

Reiterating that board-certified ob-gyns have "more-than-sufficient training" to order genetic testing and to counsel patients, ACOG cites their previously released Committee Opinion on Ethical Issues in Genetic Testing, which lays out the role ob-gyns should play in genetic counseling. Ob-gyns, it says, should be aware of: appropriate test use; which test to order; what information the test can provide and the limitations of the test; how to interpret positive and negative results in conjunction with the patient's medical or family history; and the medical management options available, including appropriate specialist referral.

Takeaway: ACOG challenges requirements for pre-test counseling for genetic tests relating to hereditary cancers.