Tumor Genomic Profiling denied as not medically necessary by Avalon Healthcare Solutions?

Avalon manages genetic/molecular testing UM for many BCBS plans. Tumor profiling per NCCN biomarker recommendations.

Confirm Avalon network status — reroute to in-network lab if denial is purely contractual. NCCN biomarker testing recommendations require panel-based testing (NSCLC: EGFR/ALK/ROS1/BRAF/KRAS/MET/RET/NTRK/ERBB2/PD-L1). ACOG #226 (2020) — cfDNA offered to all pregnancies.

## Why Avalon Healthcare Solutions Denied Tumor Genomic Profiling as "Not Medically Necessary" — and How to Appeal

Avalon Healthcare Solutions manages genomic and specialty benefit determinations and applies published clinical coverage policies that define when tumor genomic profiling (comprehensive genomic profiling, CGP) meets their definition of medical necessity. A medical-necessity denial typically means Avalon concluded that the clinical circumstances documented in the authorization request did not meet one or more criteria in their policy — for example, the cancer type, stage, or line of therapy may not have been clearly specified, or the clinical rationale for how test results would change management may not have been adequately articulated. These gaps are correctable.

## Why Medical-Necessity Denials for CGP Are Regularly Overturned

For many advanced, metastatic, rare, or treatment-refractory cancers, comprehensive genomic profiling is now part of mainstream oncology practice. When the treating oncologist can articulate a clear, specific clinical rationale — explaining how the test results would directly affect treatment selection — and that rationale is aligned with published guideline organization recommendations (such as NCCN), medical-necessity denials are frequently reversed at the internal appeal stage or on external review.

## Federal Appeal Framework

Under ACA Section 2719, you have the right to a full internal appeal and independent external review. ERISA Section 503 applies to employer-sponsored plans and requires full-and-fair review. External review must generally be requested within approximately four months of a final internal denial. Expedited review is available when delay would seriously jeopardize your health — request this explicitly for active oncology cases.

## What to Gather Before You Appeal

• Avalon's clinical coverage policy for tumor genomic profiling. Obtain it from Avalon's website or your plan's document portal. Map every listed criterion to your clinical records before writing the appeal.
• Diagnosis, staging, and pathology records. Provide the pathology report confirming tumor type and any relevant biomarker results already obtained. Confirm disease stage and current treatment status.
• Prior treatment history with dates and outcomes. If the policy requires prior lines of therapy, document each: drug name, dates, response or reason for discontinuation.
• Treating oncologist's medical-necessity letter. This is the most important document. The oncologist should: (a) state the specific cancer type, stage, and current clinical situation; (b) explain what clinical question CGP would answer that has not been answered by prior testing; (c) describe how results would directly change treatment selection; and (d) reference the applicable NCCN guideline generically to establish that CGP is consistent with standard oncology practice for this indication.

## Criteria-Mapping Structure

Address each criterion in Avalon's policy explicitly:

| Avalon criterion | Chart evidence | Document | |---|---|---| | Cancer type within covered indications | Pathology report | Report, date | | Stage/clinical situation documented | Staging workup | Chart notes | | Prior therapy history (if required) | Treatment log with dates/outcomes | Oncologist letter + records | | CGP results would change management | Specific clinical rationale | Oncologist letter |

## Practical Advice

Do not assume Avalon's internal reviewer is an oncologist. Write the letter so that any clinician can follow the logic. If the internal appeal is denied, external review by an independent oncology specialist is often the most effective route — external reviewers are not bound by Avalon's internal policy definitions and apply peer-reviewed clinical standards directly.