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    v1.0.28
    OpenPayerPolicy UpdatesEndocrinologyAmbetter Nevada Monogenic Diabetes Coverage Update…
    Ask Trek AI about this page
    CurrentAmbetter NevadaPolicy N/A

    Concert Genetic Testing: Endocrinology — Monogenic Diabetes (Including MODY) Panels

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    Defines medical necessity criteria for genetic testing panels targeting endocrine disorders—primarily monogenic diabetes/MODY—and applies to health plans affiliated with Centene (Ambetter Nevada).

    Policy Summary
    PayerAmbetter Nevada
    PolicyConcert Genetic Testing: Endocrinology — Monogenic Diabetes (Including MODY) Panels
    Policy CodePolicy N/A
    Change TypeCriteria revisions and language updates
    Effective DateN/A
    Last ReviewDec 25, 2024
    Next Review DateDec 25, 2024
    Key ActionDocument pre- and post-test genetic counseling and a plan for returning results in the medical record before ordering testing.
    SourceLink
    POLICY UPDATE CHANGES

    Changed monogenic diabetes criterion: diabetes diagnosis within first 12 months of life (was 6 months) and changed upper age from 35 to 30 years for one criterion.

    Reworded autoantibody and C-peptide criteria to remove specific numeric C-peptide values and requirement for hypoglycemia.

    Replaced statement that testing was 'investigational' for other indications with 'current evidence does not support multigene panel analysis' for other indications.

    Policy strongly advises pre-test and post-test genetic counseling and a plan for returning results.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    1primary detailed criteria set
    12 monthsinfancy diagnosis trigger
    30 yearsyounger-onset threshold
    examplesCPT codes referenced

    Coverage Criteria — Monogenic Diabetes / MODY Panels

    Monogenic Diabetes (Including MODY) Panels

    Multigene panel analysis to establish or confirm a diagnosis of monogenic diabetes (including MODY) is considered medically necessary when:

    Primary age-based criteria: A. The member/enrollee has a diagnosis of diabetes within the first 12 months of life.age<=12 months

    [[chunk 8]]

    Younger-onset criterion

    • At least one of: 1. a) Autoantibody negative; OR b) Retained C-peptide levels.

      [[chunk 8]]

    Atypical diabetes with family history

    • Family history requirement: 1. The member/enrollee has a family history of diabetes consistent with an autosomal dominant pattern of inheritance.

      [[chunk 8]]

    Other Indications (Not Supported)

    Not supported/Not medically necessary

    Other indications: Current evidence does not support multigene panel analysis to establish or confirm a diagnosis of monogenic diabetes (MODY) for all other indications.n/a

    See rationale and guidelines

    Multigene panel analysis for monogenic diabetes (including MODY) is limited to the specific clinical indications listed in this policy. Testing to establish or confirm a diagnosis is considered medically necessary only when the enrollee meets one of the listed criteria (for example: diagnosis of diabetes within the first 12 months of life; diagnosis before 30 years of age with autoantibody negativity or retained C‑peptide; or atypical diabetes with a family history consistent with autosomal dominant inheritance). Multigene panel analysis is not supported for indications other than those explicitly enumerated in Section I.

    The policy language has been updated to reflect the current evidence stance: rather than labeling non‑listed uses as 'investigational,' the document now states that current evidence does not support multigene panel analysis to establish or confirm monogenic diabetes (MODY) for indications outside those specified in Section I. This wording clarifies the evidence-based rationale for restricting panel testing to the defined clinical scenarios.

    Coding and Age Thresholds

    Referenced CPT and ICD-10 codes in tablemixed
    81403Listed in policy as a referenced CPT code for monogenic diabetes panels
    81405Listed in policy as a referenced CPT code for monogenic diabetes panels
    81406Listed in policy as a referenced CPT code for monogenic diabetes panels
    81407Listed in policy as a referenced CPT code for monogenic diabetes panels
    81479Listed in policy as a referenced CPT code for monogenic diabetes panels
    E10ICD-10 code referenced in policy (Type 1 diabetes mellitus)
    E11ICD-10 code referenced in policy (Type 2 diabetes mellitus)
    E16.1ICD-10 code referenced in policy
    E16.2ICD-10 code referenced in policy
    Age at diabetes diagnosis — key thresholds
    Infancy diagnosis thresholdDiabetes diagnosis within the first 12 months of life (changed from 6 months).
    Younger-onset thresholdDiagnosis of diabetes before 30 years of age (previously 35 years) — used with additional criteria such as autoantibody negativity or retained C‑peptide.
    Atypical presentation criterionDiagnosis of diabetes not characteristic of type 1 or type 2 diabetes plus family history consistent with autosomal dominant inheritance.

    Provider Actions, Authorization, and Documentation

    Prior Authorization

    Prior authorization required — CPT-listed multigene panels only if criteria met

    Specific multigene panel tests (referenced CPT codes such as 81403, 81405, 81406, 81407, 81479) are considered medically necessary only when the clinical criteria for monogenic diabetes/MODY are met; prior authorization may be required by the health plan.

    • Referenced CPT examples appear in the policy coding table and provider guidance.
    • Submit prior authorization when ordering multigene panel testing to confirm medical necessity per the criteria in Section I.
    Billing Rule

    Billing note — verify CPT code applicability and coverage

    Providers should follow the policy’s coding and billing guidance: verify applicable CPT codes before submission and consult the Concert Platform or payer prior authorization processes for test-specific ordering and coverage determinations.

    Background

    This policy addresses genetic testing to identify monogenic forms of diabetes (including MODY) and related endocrine genetic disorders. It defines the clinical scenarios in which multigene panel analysis is considered medically necessary—emphasizing early‑onset diabetes (notably diabetes diagnosed within the first 12 months of life), younger‑onset diabetes before 30 years with supportive laboratory or clinical features, and atypical diabetes presentations accompanied by a family history consistent with an autosomal dominant pattern. Pre‑test and post‑test genetic counseling and documentation of a plan for returning results are strongly advised and expected in clinical practice.

    Definitions

    Monogenic Diabetes (Including MODY) — definition
    DefinitionMonogenic diabetes (including MODY) refers to diabetes caused by a single-gene defect; multigene panel analysis is used to establish or confirm this diagnosis when clinical criteria are met.
    Typical indicationsInfantile diabetes (diagnosed ≤12 months), younger-onset diabetes (<30 years) with supportive features, or atypical diabetes with autosomal dominant family history.
    Testing purposeIdentify pathogenic variants that explain non–type 1/2 diabetes presentations and may inform treatment and family cascade testing.
    Genetic counseling — definition and expectations
    Scope of counselingPre-test and post-test genetic counseling that facilitates informed decision-making and addresses the possibility of secondary or incidental findings.
    Plan for results
    Policy Summary
    PayerAmbetter Nevada
    PolicyConcert Genetic Testing: Endocrinology — Monogenic Diabetes (Including MODY) Panels
    Policy CodePolicy N/A
    Change TypeCriteria revisions and language updates
    Effective DateN/A
    Last ReviewDec 25, 2024
    Next Review DateDec 25, 2024
    Key ActionDocument pre- and post-test genetic counseling and a plan for returning results in the medical record before ordering testing.
    SourceLink
    On This Page
    Coverage Criteria — Monogenic Diabetes / MODY PanelsCoding and Age ThresholdsProvider Actions, Authorization, and DocumentationBackgroundDefinitions
    • Inclusion of a CPT code in the policy is informational and does not guarantee coverage.
    • Reference the most up-to-date professional coding guidance prior to claim submission.
    Documentation Required

    Document genetic counseling and plan for returning results

    Pre-test and post-test genetic counseling that addresses possibility of secondary/incidental findings and includes a plan for returning results is strongly advised and should be documented in the medical record.

    • Document counseling discussions and the plan for returning results in the member’s medical record before testing is performed.
    Denial Risk

    Denial risk — testing unsupported if criteria not met

    Multigene panel testing for monogenic diabetes will be denied or considered not supported when the individual does not meet the listed diagnostic criteria (e.g., diagnosis not within the specified ages or lacking required clinical features/family history).

    • Covered indications are limited to: diagnosis within first 12 months of life; diagnosis before 30 years with autoantibody negative or retained C‑peptide; or atypical diabetes with autosomal dominant family history.
    • Testing for other indications is not supported by current evidence and may be denied.
    A documented plan for returning results to the patient (and family as appropriate) should be established before testing.
    Documentation recommendationPre-test and post-test counseling and the plan for return of results should be documented in the medical record when ordering genetic testing for monogenic diabetes.