Laboratory and Radiology Criteria

Trofile Assay Guidelines (07/26/23)

GENETIC TESTS

Genetic Test Forms

Criteria 

BRCA 1 and 2, HBOC, and BART Gene Test (See Hereditary Breast and Ovarian Cancer)

Cardiology (heart transplant) Gene Expression Testing (AlloMap) (07/26/23)

Chromosomal Microarray Analysis (CMA) (09/07/23)

Cystic Fibrosis (11/08/23)

Fragile X Mental Retardation 1 (FMR1) (05/05/23)

Gene Expression Profiling for Cutaneous Melanoma (11/08/23)

Gene Expression Profiling for Managing Breast Cancer (08/30/24)

Hereditary Colorectal Cancer Genetic Testing – Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MUTYH-associated Polyposis (08/30/24)

Hereditary Hemochromatosis (06/26/2024)

Hereditary Breast and Ovarian Cancer (02/22/24)

Human Platelet Antigen Genotyping (06/26/2024)

Huntington's Disease (08/30/24)

Myeloproliferative Disease Genetic Testing (12/17/2024)

Noninvasive Prenatal Testing(NIPT) Trisomy 13,18, or 21 (05/08/23)

Prostate Cancer Genomic Assay (09/07/23)

Tumor Protein 53 for Li-Fraumeni Syndrome Genetic Testing (08/30/2024)

Vibration-Controlled Fibroscan (10/03/23)