Overview:
A primary initiative of PLUGS is insurance alignment. Coverage and reimbursement for laboratory testing are influenced by favorable evidence and medical coverage policies, successful navigation of preauthorization and denial-appeal workflows by providers, labs, and patients/families, and legislation mandating coverage under specific circumstances. Our efforts focus on relationship-building, increasing awareness of the challenges faced by providers, labs, patients, and payers, and proposing solutions and resources to support access to medically appropriate laboratory tests.
If you are a patient or caregiver, please see additional resources here.
PLUGS Payer Medical Necessity Policies
The PLUGS Insurance Alignment Committee’s Medical Necessity Working Group consists of members who have experience in payer relations, and in writing and reviewing medical necessity policies. The group has produced two documents as follows. The second document is now in its public comment period, so please feel free to provide feedback to the corresponding author.
PLUGS Recommendations for Payer Medical Necessity Policies, Version 1.0
Corresponding Author: Michael Astion, MD, PhD | Michael.astion@seattlechildrens.org
Publication date, Version 1.0: March 24, 2025
Purpose. The purpose of this document is to provide ten general recommendations regarding the development, implementation, and maintenance of medical necessity policies for lab tests. The overall goal, which is encompassed in the PLUGS “guardrails” philosophy, is to block waste and abuse while allowing clinical flexibility, support for the standard of care, and reduction in administrative burden for all parties.
Version History: This document was previously posted to the PLUGS website in June 2024, as a DRAFT to solicit member feedback. The current document is Version 1.0 and incorporates the detailed feedback received from payer and lab representatives. We welcome further feedback.
Corresponding author: Julie Wiedower PhD, MS, CGC | jkaylor@guardanthealth.com
Publication Date: March 24, 2025
Purpose. The document helps standardize medical necessity policies for laboratory tests by providing a list of nine required policy elements and their rationale. Examples of language to use within a policy element is provided. Standardization helps providers and patients understand policies and decreases friction with payers.
Version History: This document is a DRAFT that is being posted to the PLUGS website on March 31, 2025, and is available for public comment, and comment from PLUGS members.
Medical Policies:
The following PLUGS® policies were developed by experts within the PLUGS network and are intended for use by insurance payers, laboratories, providers, families, and consumer groups to guide coverage and reimbursement for medically appropriate genetic tests. Microsoft Word versions available upon request.
Epilepsy Genetic Testing Policy
Rapid Genome Sequencing Policy
Genomic Sequencing in Rare Disease
Inherited Bone Marrow Failure Syndromes Policy
MELAS Genetic Testing Coverage Policy
MERFF Genetic Testing Coverage Policy
NARP Genetic Testing Coverage Policy
Mitochondrial Genetic Testing Coverage Policy
Mitochondrial DNA Deletion Syndromes Genetic Testing Coverage Policy
LHON Genetic Testing Coverage Policy
MNGIE Genetic Testing Coverage Policy
Tools for Providers
The following tools are intended to help providers, laboratory administration staff, and others navigate the preauthorization process while adhering to payer policies and utilizing available resources. The tools were created by a working group within the PLUGS Insurance Alignment Committee.
Are you a PLUGS member? Log in to see the full Preauthorization Toolkit for PLUGS Members here!