Policy Updates Prior AuthorizationHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJune 9, 2023

Carelon genetic testing CPT code list update

Effective for dates of service on and after August 1, 2023, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.*

CPT® code

Description

Clinical UM Guideline title:

81335

TPMT (thiopurine S-methyltransferase; such as drug metabolism), gene analysis, and common variants (such as *2, *3).

MCG: Azathioprine and 6-Mercaptopurine Pharmacogenetics - NUDT15 and TPMT Genes (a-6028)

 

81405

Molecular pathology procedure, Level 6 (such as analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons, regionally targeted cytogenomic array analysis), ABCD1 (ATP-binding cassette, sub-family D [ALD], member 1; such as adrenoleukodystrophy), etc.

MCG: Familial Hypercholesterolemia - APOB, LDLR, and PCSK9 Genes (A-0958)

MCG: Fabry Disease - GLA Gene (A-0916)

MCG: Noonan Syndrome - Gene and Gene Panel Testing (A-0915)

MCG: Autism Spectrum Disorders - Gene Panels (A-0914)

MCG: Loeys-Dietz Syndrome - Gene and Gene Panel Testing (A-0909)

MCG: Neurofibromatosis - NF2 Gene (A-0846)

MCG: Multiple Endocrine Neoplasia (MEN) Syndrome, Type 2 - RET Gene (A-0842)

MCG: Diabetes Mellitus (Permanent Neonatal Diabetes) - ABCC8, EIF2AK3, FOXP3, GATA4, GATA6, GCK, GLIS3, IER3IP1, INS, KCNJ11, MNX1, NEUROG3, NKX2-2, PDX1, PTF1A, and RFX6 Genes (A-0824)

MCG: Deafness and Hearing Loss, Nonsyndromic - Gene and Gene Panel Testing (A-0823)

MCG: Peutz-Jeghers Syndrome - STK11 Gene (A-0799)

MCG: Pancreatic Cancer (Hereditary) - Gene Panel (A-0797)

MCG: Marfan Syndrome - FBN1 Gene (A-0788)

MCG: Joubert Syndrome - Gene Testing and Gene Panels (A-0785)

MCG: Familial Thoracic Aortic Aneurysm and Aortic Dissection - Gene Testing and Gene Panels (A-0778)

MCG: Hereditary Hemorrhagic Telangiectasia - ACVRL1, ENG, GDF2, and SMAD4 Genes (A-0704)

MCG: Colorectal Cancer - Gene Testing (Somatic or Therapeutic) (A-0773)

MCG: Maple Syrup Urine Disease, Type 1 or Type 2 - BCKDHA, BCKDHB, and DBT Genes (A-0681)

MCG: Von Willebrand Disease - VWF Gene (A-0688)

MCG: Charcot-Marie-Tooth Hereditary Neuropathy - Gene and Gene Panel Testing (A-0691)

MCG: Familial Dilated Cardiomyopathy - Gene and Gene Panel Testing (A-0648)

MCG: Catecholaminergic Polymorphic Ventricular Tachycardia - Gene and Gene Panel Testing (A-0636)

MCG: Familial Hypertrophic Cardiomyopathy, Nonsyndromic - Gene and Gene Panel Testing (A-0633)

MCG: Pancreatitis, Hereditary - CFTR, CPA1, CTRC, PRSS1, and SPINK1 Genes (A-0646)

MCG: Wilms Tumor - WT1 Gene (A-0615)

MCG: Diabetes Mellitus (Maturity-Onset Diabetes of the Young) - ABCC8, APPL1, BLK, CEL, GCK, HNF1A, HNF1B, HNF4A, INS, KCNJ11, KLF11, NEUROD1, PAX4, and PDX1 Genes (A-0598)

MCG: Alzheimer Disease (Early Onset) - APP, PSEN1, and PSEN2 Genes (A-0590)

MCG: Multiple Endocrine Neoplasia (MEN) Syndrome, Type 1 - MEN1 Gene (A-0582)

MCG: Developmental Delay - Gene Panels (A-0925)

MCG: Age-Related Macular Degeneration - Gene Panels (A-0913)

MCG: Epilepsies (Hereditary) - Gene Panels (A-0905)

MCG: Alzheimer Disease (Late Onset) - APOE Genotyping (A-0809)

MCG: Parkinson Disease - Gene Testing and Gene Panels (A-0671)

MCG: Amyotrophic Lateral Sclerosis (ALS) - C9orf72 and SOD1 Genes (A-0591)

81403

Molecular Pathology procedure level 4

MCG: Lynch Syndrome - BRAF V600, EPCAM, MLH1, MSH2, MSH6, and PMS2 Genes and Gene Panel (A-0533)

MCG:  Von Hippel-Lindau Syndrome - VHL Gene (A-0583)

MCG: Diabetes Mellitus (Maturity-Onset Diabetes of the Young) - ABCC8, APPL1, BLK, CEL, GCK, HNF1A, HNF1B, HNF4A, INS, KCNJ11, KLF11, NEUROD1, PAX4, and PDX1 Genes (A-0598)

MCG: Familial Hypertrophic Cardiomyopathy, Nonsyndromic - Gene and Gene Panel Testing (A-0633)

MCG: Familial Dilated Cardiomyopathy - Gene and Gene Panel Testing (A-0648)

MCG: Spinal Muscular Atrophy - SMN1 and SMN2 Genes (A-0659)

MCG: Charcot-Marie-Tooth Hereditary Neuropathy - Gene and Gene Panel Testing (A-0691)

MCG: Von Willebrand Disease - VWF Gene (A-0688)

MCG: Pancreatic Cancer (Hereditary) - Gene Panel (A-0797)

MCG: Deafness and Hearing Loss, Nonsyndromic - Gene and Gene Panel Testing (A-0823)

MCG: Diabetes Mellitus (Permanent Neonatal Diabetes) - ABCC8, EIF2AK3, FOXP3, GATA4, GATA6, GCK, GLIS3, IER3IP1, INS, KCNJ11, MNX1, NEUROG3, NKX2-2, PDX1, PTF1A, and RFX6 Genes (A-0824)

MCG: Spinocerebellar Ataxia - Gene Testing and Gene Panels (A-0908)

MCG: Long QT Syndrome (Hereditary) - Gene Panel (A-0918)

MCG: Amyotrophic Lateral Sclerosis (ALS) - C9orf72 and SOD1 Genes (A-0591)

MCG: Diabetes Mellitus, Type 2 - KCNJ11, KCNQ1, PPARG, SLC16A11, and TCF7L2 Genes (A-0826)

MCG: Noninvasive Prenatal Testing (Cell-Free Fetal DNA) - Microdeletion Syndromes (A-0848)

MCG: Psychotropic Medication Pharmacogenetics - ABCB1, ADRA2A, BDNF, COMT, DRD, FKBP5, GNB3, HTR, MC4R, OGFRL1, SLC6A4, and TPH1 Genes (A-0859)

MCG: Epilepsies (Hereditary) - Gene Panels (A-0905)

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon in one of several ways:

  • Access the ProviderPortalSM directly via providerportal.com:
    • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
  • You may access the current guidelines here

The Prior Authorization Lookup Tool allows providers to search codes by the specific line of business Medicaid/SCHIP/Family Care, or Hoosier Care Connect to determine if prior authorization (PA) is required and which guideline is utilized for the case review. The Prior Authorization Lookup Tool is available at https://providers.anthem.com/in > Claims > Precertification lookup tool.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your Provider Relationship Account Manager associate or call Provider Services at:

  • Hoosier Healthwise: 866-408-6132
  • Healthy Indiana Plan: 844-533-1995
  • Hoosier Care Connect: 844-284-1798

* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

INBCBS-CD-017602-23-CPN17426

PUBLICATIONS: July 2023 Provider Newsletter