Hereditary Cancer Panel denied for missing prior authorization 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 for Prior Authorization

Carelon (formerly AIM Specialty Health) manages prior authorization for genetic testing on behalf of many health plans, and hereditary cancer panels are one of the most commonly prior-auth-required categories. A "prior auth required" denial means the test was either performed without obtaining authorization in advance, or the authorization request was submitted but did not meet Carelon's clinical criteria at the time of review. Both situations are appealable.

## Why This Denial Is Appealable

If the test was performed without prior authorization, plans are still required to evaluate medical necessity on appeal — they cannot categorically deny based on procedure alone if the service would otherwise have been covered. The medical necessity standard governs the appeal outcome, not the procedural failure. If the prior authorization was submitted and denied on clinical grounds, the denial criteria must be specifically addressed with documentation.

For urgent or emergent situations, retro-authorization and expedited appeals are available pathways.

## Federal Appeal Framework

• Internal Appeal: ACA and ERISA §503 entitle you to a full-and-fair internal appeal. File within the deadline stated on your denial notice.
• External Review: Under ACA §2719, after a final internal denial, you are entitled to independent external review by an accredited IRO, generally within four months of the final internal denial. For urgent oncologic situations, expedited external review (typically resolved within 72 hours) is available.
• Retro-Authorization: Many plans permit retro-authorization requests when clinical necessity can be documented; this is a parallel pathway to the formal appeal.

## Concrete Appeal Steps and Timeline

1. Determine the denial basis — was auth not requested, or was it requested and denied? The documentation strategy differs. 2. Request the specific criteria Carelon applied (or would apply) to authorize the test. 3. If auth was not requested: document the clinical urgency or circumstances that precluded prior auth, and present full medical necessity documentation. 4. If auth was denied on clinical grounds: address each unmet criterion with specific chart documentation. 5. File internal appeal within the stated deadline. 6. File external review if internal appeal is denied.

## Documentation to Gather

• Prescriber medical-necessity letter documenting the clinical indication and why the panel was needed at the time it was ordered
• Diagnosis records, personal and family cancer history, and any prior risk-assessment documentation
• Documentation of clinical urgency if prior auth was not feasible before testing
• Any prior authorization request records, including submission dates and Carelon's response
• Current applicable guideline from the relevant professional organization (such as NCCN) supporting the indication — obtain the current version directly from that organization
• Evidence that results will influence clinical management decisions

## Criteria-Mapping Structure

For each requirement in Carelon's prior authorization criteria, document the chart fact that satisfies it:

| Auth Criterion | Your Supporting Evidence | |---|---| | Clinical indication meets coverage criteria | Prescriber letter; family history summary; diagnosis documentation | | Results will alter management | Prescriber's statement on management implications | | Timely auth not feasible (if applicable) | Clinical urgency documentation; ordering timeline records | | Ordering provider is appropriate specialist | Credentials and referral documentation |

Even if the procedural prior-auth step was missed, a well-documented medical necessity appeal that satisfies every clinical criterion is frequently approved at the internal or external review level.