Healthcare continues to evolve, so PEIA is constantly seeking expert analysis to assure the most effective procedures and services are employed. Evidence of genetic testing's effectiveness in screening and treating certain cancers continues to mount.
As the evidence mounts to support the efficacy of these tests, PEIA modifies its covered services to incorporate them. PEIA currently utilizes United Health Care's Genetic Testing Policies that incorporate the National Comprehensive Cancer Network (NCCN) Guidelines, https://www.nccn.org/guidelines/category_1, as the basis for determining which genetic tests the plan covers. In general, these covered genetic tests have been proven effective for certain cancer screenings and treatments.
Due to the limited studies showing their efficacy, prohibitive costs associated with genetic testing and limited healthcare dollars, PEIA does not cover all genetic tests. The excluded tests are generally considered to be broad, exploratory tests, not effective in screening or treatment.
It is important that we all remain diligent in assuring covered benefits include healthcare advancements that have been proven to be effective, and that our limited healthcare dollars are spent wisely. If you believe a genetic test was inappropriately denied for a patient, please follow the appeal process outlined in the APPEALING A CLAIM section of the member's Summary Plan Description – go to Summary Plan Descriptions (wv.gov) for the most recent version. The genetic test will be reevaluated and, if evidence of the test or case warrants coverage, the denial may be overturned.