OB-GYN Groups Say Insurers' Genetic Testing Rules Limit Access to Care

Two major professional societies for obstetricians and gynecologists have issued a joint statement calling on insurers to lift requirements on who can provide genetic counseling before genetic tests are ordered, saying the rules have created “unnecessary barriers to timely care.”

The American College of Obstetricians and Gynecologists and the American Congress of Obstetricians and Gynecologists (ACOG) declared recently in Washington, DC, that recent policy decisions by insurers, including CMS, restrict their scope of practice, even though they are fully qualified to provide pretest counseling to patients.

The statement cited the college’s credentialing language, as well as a policy of the American Medical Association, which opposes “requirements for utilization of non-affiliated medical specialists or non-physicians prior to ordering genetic testing.”

This would refer to the practice employed by several insurers, notably Cigna, which began the practice of requiring that genetic testing by certified genetic counselors occur before genetic testing. The joint statement also mentions a prior authorization policy for BRCA testing from United Healthcare, which is set to take effect January 1, 2016.

According to a 2013 panel discussion hosted by The American Journal of Managed Care, which featured several certified genetic counselors as well as a physician from the American Cancer Society (ACS), requirements for pretest counseling came about after incidents in which some women made decisions based on inaccurate interpretations of test results. Otis Brawley, MD, of the ACS, said he had met women who had surgeries that turned out to be unnecessary.

Since that time, interest in genetic testing has grown, and so has demand.

“We are deeply concerned that these initiatives will prevent women from getting the care they need. With relatively few genetic counselors in the US, a requirement for all persons for which genetic testing is indicated to undergo pretesting counseling by a ‘genetics professional’ would markedly limit access to needed testing. This may be especially true in non-urban areas,” the statement read.

“A requirement for pretesting counseling in an area in which ‘genetics professionals’ are not available will potentially leave our patients with nowhere to go and without timely access to care,” the statement continued.

The counselors who spoke with AJMC during the 2013 panel acknowledged that their numbers are relatively limited, but they said they were working to meet coverage needs through solutions such as telehealth, and that women were very receptive.

Not everyone agrees with the “counseling first” policy, and some advocates of testing believe all women—even those with no family history of breast or ovarian cancer—should have access to BRCA testing. Insurers say the costs of testing every woman would be unsustainable.

Meanwhile, the field of genetic testing is changing, as more patients seek to move beyond BRCA testing alone and instead include it as part of next-generation sequencing (NGS). In May, CMS issued a draft local coverage determination to pay for BRCA testing as part of NGS, but only when independent counseling is provided both before and after testing. CMS outlined both the criteria when the patient could be tested, which includes being eligible to be testing for at least 1 other hereditary cancer.

ACOG, for its part, does not agree that its members are not qualified to counsel patients prior to testing. “ACOG reaffirms its position that obstetrician-gynecologists 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. This requirement would jeopardize our patients’ access to timely care.