Does Aetna cover genetic testing?

Genetic testing can play a crucial role in identifying hereditary conditions, informing treatment decisions, and enabling individuals to take proactive steps for their health. However, these tests are often costly –  so if you’re an Aetna member, you may be wondering: Does Aetna cover genetic testing?

In many cases, the answer is yes. Aetna does offer coverage for several types of genetic tests when they meet medical necessity criteria. But, like most insurers, Aetna has specific guidelines regarding which tests qualify, which providers can order them, and when prior authorization is required. Below, we’ll walk through what Aetna covers, how to determine your eligibility, and what to do if your request is denied.

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Does Aetna cover genetic testing?

Yes, Aetna covers a variety of genetic tests, especially when they’re medically necessary and recommended by a licensed healthcare provider. These tests can be used to assess your risk of an inherited disease, guide medication decisions, or diagnose rare conditions.

What types of genetic testing does Aetna cover?

While not every type of genetic testing is covered, Aetna may approve certain categories based on your medical history and the reason for testing. Commonly covered tests include:

• Cancer-related testing, such as BRCA1/BRCA2, for breast and ovarian cancer risk
  
• Carrier screening for prospective parents concerned about inherited conditions
  
• Diagnostic testing for rare or unexplained genetic diseases
  
• Pharmacogenetic testing to predict how you may respond to certain medications
  
• Newborn screening, when required by law or supported by clinical guidelines
  

Coverage for these tests generally requires that you meet certain medical criteria and that the test is ordered by a qualified provider.

What types of genetic testing are not covered by Aetna?

On the other hand, Aetna does not typically cover genetic testing when it’s considered elective, recreational, or experimental. This can include:

• Direct-to-consumer kits such as 23andMe or AncestryDNA
  
• Whole genome or exome sequencing that isn’t clearly tied to a treatment decision
  
• Duplicate testing or tests without clinical justification
  
• Genetic testing for curiosity or non-medical personal use
  

These tests are often not considered medically necessary and therefore fall outside coverage of most insurance plans.

Eligibility criteria for Aetna coverage for genetic testing

To qualify for coverage under Aetna, you’ll need to meet medical criteria that go beyond simply wanting a test done. Typically, the following conditions must be met:

The test must be ordered by a licensed provider, and there must be a valid medical reason, such as symptoms, family history, or risk factors. Aetna also evaluates whether the test is appropriate based on clinical guidelines and whether the lab conducting the test is in-network.

In some cases, you may also need to receive pre-test genetic counseling, especially for cancer or reproductive-related testing. This step ensures that patients understand the benefits and potential risks of genetic information.

How to know whether my Aetna insurance covers genetic testing

Before scheduling testing, it’s a good idea to check your benefits to avoid unexpected out-of-pocket costs. You can confirm your genetic testing coverage through a few different steps:

• Log in to your Aetna member portal and review your plan details under diagnostic or preventive services
  
• Call Aetna’s customer service line (listed on your insurance card) and ask about coverage for the specific test your provider recommends
  
• Ask your provider’s office to verify benefits on your behalf
  
• Check whether the testing lab is in-network and if any referrals or authorizations are needed.
  

Getting this information upfront can help you avoid denied claims or unexpected bills.

Does Aetna cover genetic testing prescriptions online?

Aetna may cover genetic testing ordered through a telehealth provider, particularly if that provider is in-network and the test meets the plan’s medical necessity criteria.

Knowing your coverage for telehealth and online prescriptions is especially important for patients using virtual care platforms for psychiatric medication management or reproductive health. These online consultations may lead to pharmacogenetic testing or carrier screening, depending on your health history and treatment goals.

Be sure to confirm that both the provider and the lab are covered under your Aetna plan before moving forward.

Why Aetna might deny genetic testing coverage

Even if a test seems medically important to you, there are several reasons Aetna might issue a denial. Common issues include:

• Lack of medical necessity
  
• No supporting documentation from your provider
  
• Use of an out-of-network or unapproved lab
  
• Tests that are still considered investigational
  
• Failing to obtain prior authorization
  

If your request is denied, you can often appeal with additional documentation or request a peer-to-peer review between your provider and Aetna’s clinical team.

Tips for improving your chances of genetic testing approval

The approval process for genetic testing can be smoother if you plan ahead and follow the right steps. Here’s how to improve your chances:

• Work with a provider who is familiar with Aetna’s medical policy on genetic testing
  
• Make sure your provider documents your personal or family medical history in detail
  
• Use an in-network lab that has experience working with Aetna plans
  
• Submit any required preauthorization paperwork well in advance of testing
  
• Consider pre-test counseling, especially for BRCA or carrier screenings
  

These steps can help ensure your request is processed efficiently and more likely to be approved.

Alternatives and savings options if Aetna doesn’t cover genetic testing

If your Aetna plan doesn’t cover the test you need, you may still have options. Many reputable labs offer reduced self-pay rates, and some have financial assistance programs for uninsured or underinsured patients.

You can also consider:

• Asking your provider about alternative or more targeted tests that may be covered
  
• Using an HSA or FSA to offset costs
  
• Exploring nonprofit resources that support patients with genetic conditions
  
• Contacting the testing lab directly to request a cash-pay discount or payment plan
  

It’s also worth checking back with your insurer annually, as policies around genetic testing can change over time.

How to get prior authorization from Aetna for genetic testing

For many genetic tests, Aetna requires prior authorization. Here’s how the process typically works:

1. Your provider submits a preauthorization request that includes your medical history and the clinical reason for testing
   
2. Aetna reviews the request based on its medical policy and clinical guidelines
   
3. A decision is issued, typically within 3 to 7 business days
   
4. If approved, you can proceed with the test; if denied, you or your provider can appeal
   

It’s important not to schedule testing until the authorization has been confirmed, unless you’re prepared to pay out of pocket.

Is genetic testing appropriate for you? 

If you think you may need genetic testing, know that Aetna does cover many types, especially when the test is medically necessary, ordered by a qualified provider, and supported by clinical guidelines. But coverage isn’t guaranteed, and knowing the rules around preauthorization, lab networks, and medical necessity can help you avoid denials or surprise costs.

Book an appointment on Klarity Health

If you’re exploring genetic testing and want to know whether it’s covered, Klarity can help. Our licensed providers can evaluate your medical history, recommend appropriate tests, and assist with getting Aetna coverage or prior authorization when needed. Book your consultation today.

Not sure if your insurance may cover genetic testing?

Providers on Klarity Health can assess your medical history and offer guidance on whether genetic testing may be appropriate and possibly covered.

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