Hereditary Cancer Panel denied as experimental or investigational by Carelon (formerly AIM)?

NCCN-aligned for hereditary cancer testing. Pre-test genetic counseling required for many panels. Avalon overlap in some plans.

GC by ABGC-certified counselor (telegenetics qualifies). NCCN BOP/COL footnotes endorse multi-gene panels when >1 syndrome on differential. Reroute to in-network lab if denial is contractual.

## Why Carelon Denied Your Hereditary Cancer Panel as Experimental

Carelon (formerly AIM Specialty Health) applies technology assessment criteria when reviewing genetic tests, and a denial labeled "experimental," "investigational," or "not medically proven" means the reviewer determined that the evidence base for the specific panel or testing methodology does not yet meet Carelon's internal evidence standard. For multi-gene hereditary cancer panels, this denial is frequently incorrect or reflects an outdated policy applied to a test that has broad professional society endorsement.

## Why This Denial Is Appealable

Hereditary cancer panels — including multi-gene tests assessing risk for conditions such as hereditary breast and ovarian cancer syndrome, Lynch syndrome, and related hereditary cancer syndromes — have been endorsed by major professional guideline bodies for specific high-risk indications. Carelon's own published coverage policies for genetic testing generally carve out coverage for guideline-supported indications. An "experimental" denial often means either (a) the clinical indication was not clearly documented, (b) the specific panel configuration exceeds what the policy covers, or (c) the policy used is out of date relative to current guidelines. All three grounds are contestable.

## Federal Appeal Framework

• Internal Appeal: ACA and ERISA §503 guarantee a full-and-fair internal appeal. File within the deadline on your denial letter.
• External Review: Under ACA §2719, a final internal denial triggers the right to independent external review by an accredited IRO. File within approximately four months of your final internal denial. For urgent oncologic situations, expedited external review (typically resolved within 72 hours) is available.
• ERISA Plans: Request the full claims file, the specific coverage policy version applied, and the Summary Plan Description.

## Concrete Appeal Steps and Timeline

1. Identify the exact policy and version Carelon applied — request this in writing. Policies are updated periodically and an older version may have been used. 2. Obtain the current applicable guideline from the relevant professional organization (such as NCCN) and confirm your indication is listed. 3. File internal appeal with supporting clinical and guideline documentation. 4. File external review if internal appeal is upheld — IROs frequently overturn experimental denials when professional society guidelines support the test.

## Documentation to Gather

• Prescriber letter documenting the specific hereditary cancer risk indication and explaining alignment with current professional guidelines
• Diagnosis records, family history documentation, and any prior risk-assessment results
• Current published guideline from the applicable professional organization confirming coverage of the specific indication — obtain directly from that organization's website
• Laboratory's clinical utility summary or analytical validation documentation, if available
• The Carelon coverage policy and evidence-review document applied — request these in your denial appeal response

## Criteria-Mapping Structure

For each requirement in Carelon's coverage policy, document the specific chart fact:

| Policy Requirement | Your Supporting Evidence | |---|---| | Guideline-supported clinical indication | Prescriber letter citing applicable guideline criteria | | Diagnosis or risk factor documented in chart | Pathology report, family history, prior test results | | Panel configuration within covered gene set | Lab order confirming genes tested align with policy |

Address the specific experimental-denial basis directly. If Carelon's policy is older than the current professional guidelines, note the publication date discrepancy explicitly in your appeal letter.