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

GENE.00001

Genetic Testing for Cancer Susceptibility

81404, 81405, 81406, 81437, 81438, 81445, 81450, 81479, 0013U, 0014U, 0056U

GENE.00002

Preimplantation Genetic Diagnosis Testing

89290, 89291

GENE.00003

Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease

81401, 81405, 81406, 83520, 84999, S3852

GENE.00005

BCR-ABL Mutation Analysis

81170, 81401

GENE.00006

Epidermal Growth Factor Receptor (EGFR) Testing

81235, 88365

GENE.00007

Cardiac Ion Channel Genetic Testing

81404, 81405, 81406, 81407, 81408 81413, 81414, S3861

GENE.00009

Gene-Based Tests for Screening, Detection and Management of Prostate Cancer

81313, 81479, 81541, 81551, 81599, 0005U, 0011M, 0047U, 0053U

GENE.00010

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.00011

Gene Expression Profiling for Managing Breast Cancer Treatment

81519,81520, 81521, 81599, 84999, S3854,  0045U

GENE.00012

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.00016

Gene Expression Profiling for Colorectal Cancer

81525, 81599, 84999

GENE.00017

Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including ARVD/C)

81403, 81405, 81406, 81407, 81408, 81439, 81479, S3865, S3866

GENE.00018

Gene Expression Profiling for Cancers of Unknown Primary Site

81404, 81406, 81540, 81599

GENE.00020

Gene Expression Profile Tests for Multiple Myeloma

81479, 81599

GENE.00021

Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies

81228, 81229, S3870, 81405

GENE.00023

Gene Expression Profiling of Melanomas

81401, 81599, 84999,

GENE.00024

DNA-Based Testing for Adolescent Idiopathic Scoliosis

0004M

GENE.00025

Molecular Profiling for the Evaluation of Malignant Tumors

81425, 81445, 81450, 81455, 81479, 81599, 88363, 0013U, 0014U, 0036U, 0037U, 0048U, 0050U, 0056U, 0057U

GENE.00026

Cell-Free Fetal DNA-Based Prenatal Screening for Fetal Aneuploidy

81420, 81422, 81479, 81507, 81599, 0009M

GENE.00028

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

GENE.00029

Genetic Testing for Breast and/or Ovarian Cancer Syndrome

81162, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81432, 81433, 81445, 81455

GENE.00030

Genetic Testing for Endocrine Gland Cancer Susceptibility

81404, 81405, 81445, 81455, 81479, S3840,

GENE.00031

Genetic Testing for PTEN Hamartoma Tumor Syndrome

81321, 81322, 81323

GENE.00033

Genetic Testing for Inherited Peripheral Neuropathies

81324, 81325, 81326, 81403, 81404, 81405, 81406, 81440, 81448, 81479

GENE.00034

SensiGene® Fetal RhD Genotyping Test

81403

GENE.00035

Genetic Testing for TP53 Mutations (Li-Fraumeni Syndrome)

81404, 81405, 81445, 81455

GENE.00036

Genetic Testing for Hereditary Pancreatitis

81222, 81223, 81224, 81401, 81404,  81405

GENE.00037

Genetic Testing for Macular Degeneration

81401, 81405, 81408, 81479, 81599

GENE.00038

Genetic Testing for Statin-Induced Myopathy

81328

GENE.00039

Genetic Testing for Frontotemporal Dementia (FTD)

81406, 81479

GENE.00040

Genetic Testing for CHARGE Syndrome

81403, 81407

GENE.00041

Short Tandem Repeat Analysis for Specimen Provenance Testing

81479, 84999, 0007U, 0020U

GENE.00042

Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) Syndrome

81406

GENE.00043

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

GENE.00044

Analysis of PIK3CA Status in Tumor Cells

81404

GENE.00045

Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers

81479, 81599

GENE.00046

Prothrombin G20210A (Factor II) Mutation Testing

81240

GENE.00047

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.



Featured In:
October 2018 Anthem Provider Newsletter - Virginia