Medical Policy Update for April 1, 2025

Added CPT codes 0547U, 0548U, and 0551U to Billing/Coding section, effective 4/1/2025. 

Reviewed by Avalon 4th Quarter 2024 CAB. Description, Policy Guidelines and References updated.  Related Policy section added, Table of Terminology removed. Updates to When Covered section: Reimbursement language regarding genetic counseling removed from criteria 1, criteria 2a edited and now reads “For individuals who have had a syncopal event and who have a Schwartz score greater than 1.” Added new coverage criteria 2b and 2c, 2b “For individuals for whom a cardiologist has a strong clinical suspicion of LQTS based on the individual’s clinical history, family history, and electrocardiogram (ECG) findings (e.g., Schwartz score greater than or equal to 3.5).” 2c “For individuals with QT prolongation (QTc greater than 480 ms for prepubescent individuals, QTc greater than 500 ms for postpubescent individuals) in the absence of other clinical conditions that might prolong the QT interval (e.g., electrolyte abnormalities, hypertrophy, bundle branch block).” Removed “asymptomatic” from former criteria 2b and is now criteria 2d. Criteria 4 edited to remove “>1” and changed to “greater than 1” for clarity. Criteria 7 edited to include genetic testing indications for SQTS affected individuals, now reads “Sequencing of short QT syndrome (SQTS)-associated genes is considered medically necessary for the following: a. For individuals for whom a cardiologist has a strong clinical suspicion of SQTS based on the individual’s clinical history, family history, and ECG findings (e.g., abnormally short QT intervals [less than or equal to 360 ms in males; less than or equal to 370 ms in females], an increased propensity to develop atrial and ventricular tachyarrhythmia in the absence of structural heart disease). b. Testing for the known familial likely pathogenic or pathogenic variant in asymptomatic individuals with a close relative (see Note 1) with a known SQTS likely pathogenic or pathogenic variant.” Criteria 3, 5a, 6b, 7b, 9, 10b, 11, 12, 13b, 15, and 16, changed “mutations” to “likely pathogenic or pathogenic variant”. Coverage criteria 14 changed “patients” to “individuals” for clarity. Updates to Not Covered section: criteria 1 changed “mutations” to “likely pathogenic or pathogenic variant”. Coverage criteria 1, 3 and 8 changed “patients” to “individuals” for clarity. Changed “1st-degree”, “2nd-degree”, and “3rd-degree” to “first-degree”, “second-degree”, and “third-degree” in Note 1. Removed CPT code 96040, S0265 from Billing/Coding section. Medical Director review 1/2025.

Reviewed by Avalon 4th Quarter 2024 CAB. Title changed to Genetic Testing for Muscular Dystrophies AHS-M2074. Updated Description, Policy Guidelines and References sections. Updates to When Covered and Not Covered sections: included gene name “dystrophin (DMD)” in CC1, removed former CC4, as preconception/prenatal screening is managed in M2179 and preimplantation testing is managed in M2039, new CC4, 5, and 6: “4. For individuals with clinical signs of congenital muscular dystrophy (CMD), genetic testing to confirm a diagnosis of CMD is considered medically necessary. 5. For individuals for whom genetic testing was negative for dystrophinopathies, FSHD, LGMD, or CMD, but for whom the clinical suspicion of a muscular dystrophy remains, genetic testing for rare muscular dystrophies (e.g., myotonic dystrophy, Emery-Dreifuss muscular dystrophy, oculopharyngeal muscular dystrophy, distal muscular dystrophy) is considered medically necessary. 6. For first- and second-degree relatives (see Note 1) of individuals with a muscular dystrophy, the following genetic testing is considered medically necessary: A. Testing restricted to the known familial likely pathogenic or pathogenic variant. B. Comprehensive disorder specific genetic testing when the specific familial likely pathogenic or pathogenic variant is unknown.”, addition of CC6 results in removal of relative testing in CC1, CC edited to reflect change. Now reads: “1. For individuals with clinical signs of a dystrophinopathy, genetic testing for likely pathogenic or pathogenic variants of dystrophin (DMD) is considered medically necessary.”, CC3 now allowing LGMD testing for all those with suspected LGMD: “3. For individuals who are clinically suspected of having limb-girdle muscular dystrophy (LGMD), genetic testing for likely pathogenic or pathogenic variants associated with LGMD is considered medically necessary.”, familial risk testing now addressed in new CC1 in Not Covered section, results in removal of CC5 pertaining to familial risk testing for LGMD, former CC1, 2, and 3 combined into a single CC1 under Not Covered section: “For all other situations not discussed above, genetic testing for muscular dystrophies is considered investigational.” Note 1 edited to reflect that only first- and second-degree relative testing is permitted within the policy. New Note 2: “Note 2: For two or more gene tests being run on the same platform, please refer to Laboratory Procedures Medical Policy AHS-R2162.” Updates to Billing/Coding section: added code 81187, 81234, 81239, 81312, and S3853,

removed code 81407. Medical Director review 1/2025.

Reviewed by Avalon 4th Quarter 2024 CAB. Policy Guidelines and References sections updated. When Covered section edited to replace “mutation” with “likely pathogenic or pathogenic variant” in coverage criteria 2. A. and 2. B. Code 81403 added to Billing/Coding section. Medical Director review 1/2025.

HCPCS code L5827 added to Billing/Coding section effective 4/1/25.

Reviewed by Avalon 4th Quarter 2024 CAB. Medical Director review 12/2024. Under “When Covered” section: added coverage criteria for NavDx® to detect HPV oropharyngeal squamous cell carcinoma. Updated policy guidelines, guidelines/recommendations and added references. Added PLA code 0356U in Billing/Coding section.

Code 0531U added to Billing/Coding section, effective 4/1/2025.

Code 0533U added to Billing/Coding section, effective 4/1/2025.

Updated Billing/Coding section to add 0536U, effective 4/1/2025.

Reviewed by Avalon 4th Quarter 2024 CAB. Medical Director review 12/2024. Removed M2030-Testing for Targeted Therapy for NCSLC from related policies section. Updated policy guidelines and references. No change to policy statement.

Updated Billing/Coding section to add CPT codes A2030, A2031, A2032, A2033, A2034, A2035, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4360, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, and Q4367, effective 4/1/2025.

Codes 0540U and 0544U added to Billing/Coding section, effective 4/1/2025.

Code 0549U added to Billing/Coding section effective 4/1/25.

New codes effective 4/1/25: E1022, E1023, E1032, E1033 and E1034. Codes are included in code range E0950-E1298 listed under the Billing/Coding section.