Effective August 1, 2025: Genetic Testing PLA Expansion

Date: 05/01/25

Effective August 1, 2025, prior authorization will be required for Ambetter from Superior HealthPlan members for additional genetic testing Proprietary Laboratory Analyses (PLA) codes that were evaluated and added to Evolent’s Genetic Testing Clinical Guidelines. There were no clinical criteria changes to policy as a result of this code update.

Prior authorization requests for members of all ages should be submitted to Evolent’s webpage, or by calling 1-800-642-7554 or faxing to 1-800-784-6864.

Ambetter ensures medical necessity review criteria is current and appropriate for members and the scope of services provided. The codes impacted by this change are:

PLA Code	Description	Criteria
0340U	ONC PAN CANCER ANALYSIS MRD FROM PLASMA	Evolent’s Genetic Testing Clinical Guidelines that will be utilized for these services can be found on Evolent’s Genetic Testing webpage.
0422U	ONC PAN SOLID TUM ALYS DNA BMRK RSPSE ANTCA THER
0488U	OB FTL AG NIPT CFDNA SEQ ALYS DETCJ FTL PRESENCE
0532U	RARE DS RAPID WHL GEN AND MITOCHDRL DNA SEQ SNV SLV
0533U	RX METAB ADVRS RX RXN AND RSPSE GNOTYP 16 GENES
0534U	ONC PRST8 MIRNA SNP ALYS RT-PCR 32VRNT BUCC SWAB
0536U	RBC AG FETAL RHD PCR ALYS EXON 4 RHD GENE AND GAPDH
0538U	ONC SOLID TUM NGTS ALYS FFPE DNA ALYS 600 GENES
0539U	ONC SOLID TUMOR CFCTDNA 152 GEN NGS INTERROG SNV
0543U	ONC SOL TUM NGS DNA FFPE TISS 517GEN INTEROG SNV
0549U	ONC URTHL DNA QUAN MTHYLTD RT PCR TRNA-CYS SIM2
0523U	ONC SOLID TUMOR DNA QUAL NGS SNV 22GEN FFPE TISS
0530U	ONC PAN-SOL TUM CTDNA PLSM NGS 77 GEN 8 FUJN MSI

To review Evolent’s prior authorization requirements, please visit Evolent's webpage.

For questions or additional information, contact Ambetter’s Prior Authorization department at 1-877-687-1196.