age limits on genetic testing… seemingly arbitrary?

I’ve recently had a geneticist and genetic counselor recommend whole exome sequencing. I reviewed my insurer’s medical policy on coverage of whole exome sequencing (WES) and I meeting all of their criteria for “medical necessity”, EASILY…. except for one. One of the criteria for determining medical necessity of WES is an age less than 18. A quick search of other insurers policies show a similar practice (some its under 19 or 21). What I cannot find is a solid reasoning behind the seemingly arbitrary age limit.

I can see the claim has already been quickly denied, not surprising and having a lot of experience appealing (and winning) stuff with them I’m sure this is why it was denied. My teams documentation clearly showed how I met all of the other criteria, so it would be next to impossible for them to deny for a different reason (although not completely unexpected as they seem to like to deny things just because they know 90% of people won’t bother to appeal).

Problem is I’m at a bit of a loss on how to go about appealing this one as I’m unable to determine WHY they believe it’s only medically necessary in members under the age of 18… is there some huge change that comes about genetically at the age of 19 that makes people suddenly overcome a potential genetic disorder that makes this kind of testing obsolete in them? Highly doubtful, but that’s the only reason I could see as valid for such a restriction.

My gut is telling me that this age restriction is somewhat discriminatory and without any relevant evidence based research to support it… problem is I’m also having trouble finding something that says anything specific about testing in those over 18 (or under 18)…. it’s not that it’s not done or recommended, but all studies were fairly generalized. It’s proving difficult to disprove something that was never proven in the first place…. if that makes sense? I fear this one may be more difficult to overturn. ๐Ÿ™

Any suggestions?

โ€‹

TL/DR: insurer denied whole exome sequencing because they only cover it for members under the age of 18, but seemingly no evidence can be found to support any age restriction

submitted by /u/dreamingjes
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I’ve recently had a geneticist and genetic counselor recommend whole exome sequencing. I reviewed my insurer’s medical policy on coverage of whole exome sequencing (WES) and I meeting all of their criteria for “medical necessity”, EASILY…. except for one. One of the criteria for determining medical necessity of WES is an age less than 18. A quick search of other insurers policies show a similar practice (some its under 19 or 21). What I cannot find is a solid reasoning behind the seemingly arbitrary age limit. I can see the claim has already been quickly denied, not surprising and having a lot of experience appealing (and winning) stuff with them I’m sure this is why it was denied. My teams documentation clearly showed how I met all of the other criteria, so it would be next to impossible for them to deny for a different reason (although not completely unexpected as they seem to like to deny things just because they know 90% of people won’t bother to appeal). Problem is I’m at a bit of a loss on how to go about appealing this one as I’m unable to determine WHY they believe it’s only medically necessary in members under the age of 18… is there some huge change that comes about genetically at the age of 19 that makes people suddenly overcome a potential genetic disorder that makes this kind of testing obsolete in them? Highly doubtful, but that’s the only reason I could see as valid for such a restriction. My gut is telling me that this age restriction is somewhat discriminatory and without any relevant evidence based research to support it… problem is I’m also having trouble finding something that says anything specific about testing in those over 18 (or under 18)…. it’s not that it’s not done or recommended, but all studies were fairly generalized. It’s proving difficult to disprove something that was never proven in the first place…. if that makes sense? I fear this one may be more difficult to overturn. ๐Ÿ™ Any suggestions? โ€‹ TL/DR: insurer denied whole exome sequencing because they only cover it for members under the age of 18, but seemingly no evidence can be found to support any age restriction
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