Anthem Blue Cross and Blue Shield | CommercialOctober 1, 2018
Prior authorization for genetic testing
Effective with dates of service on and after November 1, 2018, Anthem Blue Cross and Blue Shield will transition the medical necessity review of all genetic testing services for members enrolled in our PPO health benefit plans to AIM Specialty Health® (AIM), a separate company. This review will take place as a prior authorization.
SPECIAL NOTE: For members enrolled in our affiliate HealthKeepers, Inc.'s Anthem HealthKeepers commercial health plans, there are no changes in the medical necessity review of genetic testing services. Anthem in Virginia will continue to handle the medical necessity review locally for Anthem HealthKeepers members.
The coverage guidelines and codes that will be reviewed by Anthem plans managed by AIM for medical necessity include:
Coverage Guideline # |
Coverage Guideline Title |
Codes |
Genetic Testing for Cancer Susceptibility |
81404, 81405, 81406, 81437, 81438, 81445, 81450, 81479, 0013U, 0014U, 0056U |
|
Preimplantation Genetic Diagnosis Testing |
89290, 89291 |
|
Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease |
81401, 81405, 81406, 83520, 84999, S3852 |
|
BCR-ABL Mutation Analysis |
81170, 81401 |
|
Epidermal Growth Factor Receptor (EGFR) Testing |
81235, 88365 |
|
Cardiac Ion Channel Genetic Testing |
81404, 81405, 81406, 81407, 81408 81413, 81414, S3861 |
|
Gene-Based Tests for Screening, Detection and Management of Prostate Cancer |
81313, 81479, 81541, 81551, 81599, 0005U, 0011M, 0047U, 0053U |
|
Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status |
81225, 81226, 81227, 81230, 81231,81232, 81346, 81350, 81355, 81381, 81479, G9143, 0028U, 0029U, 0030U, 0031U, 0032U, 0033U, G9143
|
|
Gene Expression Profiling for Managing Breast Cancer Treatment |
81519,81520, 81521, 81599, 84999, S3854, 0045U |
|
Preconceptional or Prenatal Genetic Testing of a Parent or Prospective Parent |
81200, 81209, 81220, 81221, 81222, 81223, 81224, 81241, 81242, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81269, 81290, 81330, 81361, 81362, 81363, 81364, 81401, 81403, 81404, 81405, 81406, 81412, 81415, 81416, 81417, 81425, 81426, 81427, 81479, S3800, S3841, S3842, S3844, S3845, S3846, S3849, S3853, 0012U |
|
Gene Expression Profiling for Colorectal Cancer |
81525, 81599, 84999 |
|
Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including ARVD/C) |
81403, 81405, 81406, 81407, 81408, 81439, 81479, S3865, S3866 |
|
Gene Expression Profiling for Cancers of Unknown Primary Site |
81404, 81406, 81540, 81599 |
|
Gene Expression Profile Tests for Multiple Myeloma |
81479, 81599 |
|
Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies |
81228, 81229, S3870, 81405 |
|
Gene Expression Profiling of Melanomas |
81401, 81599, 84999, |
|
DNA-Based Testing for Adolescent Idiopathic Scoliosis |
0004M |
|
Molecular Profiling for the Evaluation of Malignant Tumors |
81425, 81445, 81450, 81455, 81479, 81599, 88363, 0013U, 0014U, 0036U, 0037U, 0048U, 0050U, 0056U, 0057U |
|
Cell-Free Fetal DNA-Based Prenatal Screening for Fetal Aneuploidy |
81420, 81422, 81479, 81507, 81599, 0009M |
|
Genetic Testing for Colorectal Cancer Susceptibility |
81201, 81202, 81203, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81401, 81403, 81406, 81435, 81436 |
|
Genetic Testing for Breast and/or Ovarian Cancer Syndrome |
81162, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81432, 81433, 81445, 81455 |
|
Genetic Testing for Endocrine Gland Cancer Susceptibility |
81404, 81405, 81445, 81455, 81479, S3840, |
|
Genetic Testing for PTEN Hamartoma Tumor Syndrome |
81321, 81322, 81323 |
|
Genetic Testing for Inherited Peripheral Neuropathies |
81324, 81325, 81326, 81403, 81404, 81405, 81406, 81440, 81448, 81479 |
|
SensiGene® Fetal RhD Genotyping Test |
81403 |
|
Genetic Testing for TP53 Mutations (Li-Fraumeni Syndrome) |
81404, 81405, 81445, 81455 |
|
Genetic Testing for Hereditary Pancreatitis |
81222, 81223, 81224, 81401, 81404, 81405 |
|
Genetic Testing for Macular Degeneration |
81401, 81405, 81408, 81479, 81599 |
|
Genetic Testing for Statin-Induced Myopathy |
81328 |
|
Genetic Testing for Frontotemporal Dementia (FTD) |
81406, 81479 |
|
Genetic Testing for CHARGE Syndrome |
81403, 81407 |
|
Short Tandem Repeat Analysis for Specimen Provenance Testing |
81479, 84999, 0007U, 0020U |
|
Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) Syndrome |
81406 |
|
Genetic Testing of an Individual’s Genome for Inherited Diseases |
81200, 81209, 81221, 81222, 81223, 81224, 81241, 81242, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81269, 81290, 81330, 81361, 81362, 81363, 81364, 81400, 81403, 81404, 81405, 81406, 81408 81410, 81411, 81412, 81415, 81416, 81417, 81425, 81426, 81427, 81430, 81431, 81434, 81440, 81442, 81460, 81465, 81470, 81471, 81479, 81599, 81493, 81506, 81599, S3800, S3841, S3842, S3844, S3845, S3846, S3849, S3853, 0012U |
|
Analysis of PIK3CA Status in Tumor Cells |
81404 |
|
Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers |
81479, 81599 |
|
Prothrombin G20210A (Factor II) Mutation Testing |
81240 |
|
Methylenetetrahydrofolate Reductase Mutation Testing |
81291 |
|
CG-GENE-01 |
Janus Kinase 2 (JAK2) V617F Gene Mutation Assay |
81270, 81403 |
CG-GENE-02 |
Analysis of Kras Status |
81275, 81276, 81479, 88363, |
CG-GENE-03 |
BRAF Mutation Analysis |
81210, , 81406, 88363 |
CG GENE 04 |
Molecular Marker Evaluation of Thyroid Nodules |
81545, 81599, 0018U, 0026U |
Beginning October 22, 2018, prior authorization requests for dates of service on or after November 1, 2018, may be submitted to AIM using one of the following ways:
- Access AIM ProviderPortalSM directly at 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.
- Access AIM via the Availity Web Portal at availity.com.
- Call the AIM Contact Center toll-free number: 866-789-0158, Monday – Friday, 8 a.m. to 5 p.m. ET.
For more information about genetic testing prior authorization, visit AIM’s Genetic Test Site. Precertification requirements for Anthem members can be viewed at anthem.com.
Please note, this program does not apply to the Federal Employee Program® (FEP®) or HealthKeepers, Inc. health plans. Anthem in Virginia will continue to handle the medical necessity review of genetic testing services locally for members enrolled in Anthem HealthKeepers commercial health plans.
For questions regarding prior authorization requirements, please contact the provider service number on the back of the member ID card.
PUBLICATIONS: October 2018 Anthem Provider Newsletter - Virginia
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Visit https://providernews.anthem.com/virginia/articles/prior-authorization-for-genetic-testing-737
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