Diagnosis: family history of cancer
Treatment: genetic testing
The insurer denied genetic testing.

The health plan's determination is upheld.

The patient is a female with family history of cancer in her mother (colorectal). Genetic Testing was ordered for deoxyribonucleic acid (DNA) Sequence Analysis. The health plan denied it as not medically necessary.

No, the patient did not meet minimal clinical criteria for Lynch testing and therefore genetic testing would have a low yield and would not be indicated or medically necessary. Moreover, the Lynch testing may potentially be harmful if it results in a variant of unclear significance (VUS) which would be difficult to interpret and may necessitate further unnecessary testing of the patient and family members. The patient did not fulfill either Amsterdam I or Amsterdam II criteria:
Amsterdam I criteria (all 4 must be met):
1) Three or more family members, one of whom is a first-degree relative of the other two, with a confirmed diagnosis of colorectal cancer (not met since only her mother had colorectal cancer based on the pedigree)
2) Two successive affected generations (not met)
3) One or more colon cancers diagnosed before age 50 years (not met)
4) Exclusion of familial adenomatous polyposis (met)
Amsterdam II criteria (all 4 must be met):
5) Three or more family members (one of whom is a first-degree relative of the other two) with HNPCC (Hereditary nonpolyposis colorectal cancer)-related cancers (not met)
6) Two successive affected generations (not met)
7) One or more of the HNPCC-related cancers diagnosed before age 50 years (not met)
8) Exclusion of familial adenomatous polyposis (met).

The health plan's determination is upheld.