by Vincent A. Toreno, Esq.

We are seeing a rising trend in requests for authorization of “one-time” genetic testing. Healthcare providers are requesting the testing to assist in effectively prescribing medications for the injured employee, claiming the tests help pinpoint the most beneficial medications with the least side effects as well as appropriate dosages and addiction risks. Although the testing only needs to be performed once per patient, it is expensive and therefore employers and insurers should carefully evaluate each case, as well as question the physician, to determine whether the testing is medically appropriate and makes economic sense in that particular situation.

This emerging field known as pharmacogenomics, or drug-gene testing, is a process that analyzes an individual’s genetic make-up purportedly to determine the individual’s ability to metabolize certain medicines. The idea is that the testing will determine the medicines and doses more likely to be effective based on the patient’s genetic make-up. We all inherit genes that impact certain characteristics such as eye and hair color, but we also inherit genes that determine how well our bodies respond to medicines. While this is a new and emerging field, the science upon which it is based is being developed at prestigious and well respected institutions such as the Mayo Clinic. Indeed, Medicare recently agreed to begin paying for drug-gene testing in treating depression where the patient has tried at least one depression medication without success.

However, drug-gene testing has its limitations. First, it is expensive. CPT codes used for the testing are 81225 ($396.46), 81226 ($613.57) and 81227 ($237.87), for a total of $1,247.90 under the Georgia Workers’ Compensation fee schedule. Often, more than one panel is required because testing may need to be conducted for each medication the patient uses. Additionally, there are many medications for which no testing is currently available, including tests for over-the-counter medications such as aspirin and other pain relievers. More importantly, some physicians and scientists are urging caution, claiming the science behind drug-gene testing is not sufficiently supported by good research. Some physicians point out that pharmacogenomics testing is not a panacea; rather, it simply one tool to assist in determining which medication is best. Other factors such as age, lifestyle and other medications must also be considered.

It is also important to understand that drug-gene testing is not currently regulated by the FDA, although the FDA has announced that will change over the next several years. For the time being, companies that provide this service are not governed by the same rules and scrutiny as drug manufacturers nor are they required to disclose physicians who are paid to promote their service. Thus, patients are unable to find out whether the doctor stands to gain financially by recommending the test.

As with all emerging technologies, it is important to take a cautious approach. Analyze the claim and question the physician who is requesting the testing. Are the prescription costs high? Is the claimant on a lot of medications or having adverse side effects on their current prescription regimen? Is the claimant’s pain and condition well controlled or has the physician needed to take a “trial and error” approach to find the right prescription?

While the Georgia Composite Medical Board has rules which require monitoring and random drug testing in certain cases involving controlled substances, genetic testing is not mandated and therefore employer and insurers can choose not to authorize this testing if it is not medically warranted.