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CPT 81415: Exome Sequence Analysis for Unexplained Disorders
CPT code 81415 denotes exome sequencing analysis used to investigate unexplained disorders or syndromes by evaluating the protein-coding regions of the genome. This molecular diagnostic procedure is increasingly important for identifying genetic causes of rare, congenital, or complex clinical presentations and can inform diagnosis and subsequent management decisions. Nationally, exome sequencing contributes to precision medicine initiatives and affects laboratory workflows, payer coverage determinations, and utilization patterns across clinical genetics services.
Key payers in coverage discussions include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication provides an overview of coverage policies and typical billing practices among these payers, plus comparisons to related molecular testing codes.
Readers will learn the clinical context for CPT code 81415, typical sites of service, common coding relationships to related molecular pathology procedures, and the landscape of payer coverage nomenclature. The summary highlights where CPT 81415 sits relative to other genomic tests and what stakeholders should consider when documenting medical necessity and selecting appropriate genetic testing pathways. Data not available in the input will be noted where applicable.
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Billing Code Overview
CPT code 81415 describes an exome gene sequence analysis performed by a laboratory analyst to identify genetic variants that could explain an unexplained disorder or syndrome in a patient. This service involves sequencing the protein-coding regions of the genome to detect single-nucleotide variants and small insertions/deletions that may underlie a clinical presentation.
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Service type: Clinical molecular diagnostic testing (exome sequencing)
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Typical site of service: Clinical laboratory or hospital-based molecular diagnostics laboratory
National Reimbursement Benchmarks
National commercial rates for CPT 81415 center on BUCA’s mean commercial rate of $4,572.10, which provides a useful midpoint for market comparisons. Blue Cross Blue Shield has the highest dispersion between its 25th and 75th percentiles ($5,427.50 - $3,798.30 = $1,629.20), indicating wider variability in allowed commercial rates, while Aetna’s interquartile spread ($3,824.00 - $1,000.00 = $2,824.00) is even larger, reflecting substantial skew from low-percentile contracts to high outliers.
UnitedHealth Group shows a tighter middle distribution with an IQR of $4,780.00 - $2,007.60 = $2,772.40, and Cigna’s interquartile range is $6,177.50 - $2,444.90 = $3,732.60, the widest of the listed payers. Overall, BUCA’s mean at $4,572.10 sits near the center of commercial market rates, while payer-specific IQRs highlight material differences in how concentrated allowed amounts are across insurers.