June 2010
Genetic testing codes to be reviewed
Effective May 1, several Healthcare Common Procedure Coding System (HCPCS) codes are now reviewed for medical necessity or as potentially investigational. The majority of these codes will require pre-authorization beginning September 1.
Claims that include the following genetic tests, requiring pre-authorization, will be reviewed for medical necessity:
- HCPCS S3818-S3823 Analysis for BRCA 1 and/or BRCA 2 gene
- HCPCS S3828-S3831 Analysis for MLH1 and/or MLH2 gene
- HCPCS S3833-S3834 Analysis for familial adenomatous polyposis (FAP)
- HCPCS S3840 DNA analysis for germline mutations of the RET proto-oncogene for susceptibility to multiple endocrine neoplasia type 2
Claims that include the following genetic tests, requiring pre-authorization, will be reviewed as potentially investigational:
- HCPCS S3800 Genetic testing for amyotrophic lateral sclerosis (ALS)
- HCPCS S3843 DNA analysis of the F5 gene for susceptibility to factor V Leiden thrombophilia
- HCPCS S3844 DNA analysis of the connexin 26 gene (GJB2) for susceptibility to congenital, profound deafness
- HCPCS S3845 Genetic testing for alpha-thalassemia
- HCPCS S3846 Genetic testing for hemoglobin E beta-thalassemia
- HCPCS S3847 Genetic testing for Tay-Sachs disease
- HCPCS S3848 Genetic testing for Gaucher disease
- HCPCS S3849 Genetic testing for Niemann-Pick disease
- HCPCS S3850 Genetic testing for sickle cell anemia
- HCPCS S3851 Genetic testing for Canavan disease
- HCPCS S3853 Genetic testing for myotonic muscular dystrophy
Providers are responsible to obtain pre-authorization, when required. Failure to do so will result in denial of the claim.
Claims that include the following genetic tests will be reviewed as potentially investigational but do not require pre-authorization:
- HCPCS S3860-S3866 Cardiac genetic testing
- HCPCS S3870 Comparative genomic hybrization (CGH) microarray testing for developmental delay, autism spectrum disorder and/or mental retardation
Medical records will be requested for claims that include one or more of these codes.
Additional resources:
- Please refer to our Genetic and Molecular Diagnostic Testing (Genetic Testing #20) policy at http://blue.regence.com/trgmedpol/geneticTesting/gt20.html.
- View information about other Investigational and medical necessity reviews.