ModifiedAmbetter NevadaPolicy N/A

Concert Genetic Testing: Nutrition and Metabolism

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This policy governs medical necessity for selected genetic and molecular tests used to evaluate nutrition and metabolism conditions, including G6PD variant analysis, MTHFR variant analysis, and testing for specified metabolic disorders.

Policy Summary

PayerAmbetter Nevada

PolicyConcert Genetic Testing: Nutrition and Metabolism

Policy CodePolicy N/A

Change TypeModified

Effective DateMay 1, 2026

Last ReviewNov 1, 2025

Next Review DateN/A

Key ActionDocument clinical features consistent with the suspected metabolic disorder and explain how testing will guide management.

SourceLink

POLICY UPDATE CHANGES

A new policy was created for nutrition and metabolism genetic testing, incorporating criteria from prior G6PD, MTHFR, and metabolic disorder policies.

Prior investigational statements were revised to state that current evidence does not support G6PD and MTHFR variant analysis for the listed indications.

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.

ModifiedAmbetter NevadaPolicy N/A

Concert Genetic Testing: Nutrition and Metabolism

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Sign up for all Ambetter Nevada policy alerts

Know when Ambetter Nevada releases new policies or updates existing guidance.

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Policy Summary

PayerAmbetter Nevada

PolicyConcert Genetic Testing: Nutrition and Metabolism

Policy CodePolicy N/A

Change TypeModified

Effective DateMay 1, 2026

Last ReviewNov 1, 2025

Next Review DateN/A

Key ActionDocument clinical features consistent with the suspected metabolic disorder and explain how testing will guide management.

SourceLink

POLICY UPDATE CHANGES

A new policy was created for nutrition and metabolism genetic testing, incorporating criteria from prior G6PD, MTHFR, and metabolic disorder policies.

Prior investigational statements were revised to state that current evidence does not support G6PD and MTHFR variant analysis for the listed indications.

Coverage Criteria

G6PD Variant Analysis

Current evidence does not support the test for any indication.

G6PD variant analysis: Current evidence does not support G6PD variant analysis to confirm or establish a diagnosis of glucose-6-phosphate dehydrogenase deficiency for all indications.

G6PD deficiency can be diagnosed by quantitative spectrophotometric analysis or, more commonly, a rapid fluorescent spot test detecting NADPH generation from NADP.

MTHFR Variant Analysis

Current evidence does not support the test for the listed indications.

MTHFR targeted variant analysis: Current evidence does not support MTHFR targeted variant analysis, including 677T or 1298C, for all indications, including evaluation for thrombophilia or recurrent pregnancy loss, evaluation of at-risk relatives, and drug metabolism such as pharmacogenetic testing.

Other Covered Metabolic Disorders

Covered when both of the following are met.

Medical necessity for listed metabolic disorders

ONE of the listed metabolic conditions: The suspected condition is one of the covered disorders listed in the policy, including congenital adrenal hyperplasia; congenital disorders of glycosylation; congenital hyperinsulinism; disorders of amino acid and peptide metabolism; disorders of biotin metabolism; disorders of carnitine transport and the carnitine cycle; disorders of copper metabolism; disorders of fatty acid oxidation; disorders of galactose metabolism; disorders of glucose transport; disorders of phenylalanine or tyrosine metabolism; disorders of porphyrin and heme metabolism; fibrous dysplasia/McCune-Albright syndrome; glycogen storage disorders; hypophosphatasia; Kallmann syndrome; lysosomal storage disorders; urea cycle disorders; malignant hyperthermia; or SHOX deficiency disorders.
The list is not comprehensive.
Clinical features and management relevance: The member/enrollee demonstrates clinical features consistent with the suspected disorder, and genetic testing to establish or confirm the diagnosis will guide management.
Clinical features may be supported by GeneReviews, OMIM, the National Library of Medicine, Genetics Home Reference, or other scholarly sources.

Metabolic Disorders Not Specifically Addressed

Other metabolic disorders are evaluated under the General Approach to Laboratory Testing policy.

Other metabolic disorders: Genetic testing to establish or confirm the diagnosis of a metabolic disorder not specifically discussed within this policy or another medical policy is evaluated using the criteria in the General Approach to Laboratory Testing policy.

G6PD variant analysis is not supported to confirm or establish a diagnosis of glucose-6-phosphate dehydrogenase deficiency for any indication.

MTHFR targeted variant analysis, including 677T and 1298C testing, is not supported for evaluation of thrombophilia or recurrent pregnancy loss, evaluation of at-risk relatives, or drug metabolism such as pharmacogenetic testing.

Testing to establish or confirm a listed metabolic disorder is not medically necessary when the member/enrollee does not demonstrate clinical features consistent with the suspected disorder or when the test result will not guide management.

Coding

G6PD Variant AnalysismixedNot Covered

81247	G6PD Targeted Variant - Single Test (GeneDx)
81248	G6PD Targeted Variant - Single Test (GeneDx)
81249	G6PD Targeted Variant - Single Test (GeneDx)
81479	G6PD Full Gene Sequencing
D55.0	Glucose-6-phosphate dehydrogenase [G6PD] deficiency anemia

MTHFR Variant AnalysismixedNot Covered

81291	Methylenetetrahydrofolate Reductase (MTHFR) Thermolabile Variant, DNA Analysis (LabCorp)
E03.9	Hypothyroidism, unspecified
E55.9	Vitamin D deficiency, unspecified
E72.12	Methylenetetrahydrofolate reductase deficiency
E78.2	Mixed hyperlipidemia
E78.5	Hyperlipidemia, unspecified
E88.9	Metabolic disorder, unspecified
N96	Recurrent pregnancy loss
O03	Spontaneous abortion
R53.83	Other fatigue

1–10 of 11

1/2

Other Covered Metabolic DisordersCPTCovered

81400	Other covered metabolic disorders
81401	Other covered metabolic disorders
81402	Other covered metabolic disorders
81403	Other covered metabolic disorders
81404	Other covered metabolic disorders
81405	Other covered metabolic disorders
81406	Other covered metabolic disorders
81407	Other covered metabolic disorders

Provider Actions

Note

Review Medicare Coverage Guidance

For Medicare members/enrollees, review all applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles before applying this clinical policy’s criteria. Refer to the CMS website for additional information.

Review applicable NCDs, LCDs, and Medicare Coverage Articles before applying the policy criteria.

Documentation Required

Document Consistent Clinical Features

Before ordering genetic testing to establish or confirm an applicable metabolic condition, document clinical features consistent with the suspected disorder. Clinical features may be supported by authoritative resources such as GeneReviews, OMIM, the National Library of Medicine, Genetics Home Reference, or other scholarly sources.

Document the member’s clinical features and their consistency with the suspected metabolic disorder.
Use disorder-specific clinical-feature references when appropriate.

Covered Indications

Establishing or Confirming a Diagnosis of a Listed Metabolic Disorder

Genetic testing is considered medically necessary when both of the following are met.

Establishing or confirming a diagnosis of a listed metabolic disorder

ONE of the listed metabolic disorders: The testing is intended to establish or confirm the diagnosis of one of the metabolic disorders listed in the policy.
The listed disorders include congenital adrenal hyperplasia; congenital disorders of glycosylation; congenital hyperinsulinism; disorders of amino acid and peptide metabolism; disorders of biotin metabolism; disorders of carnitine transport and the carnitine cycle; disorders of copper metabolism; disorders of fatty acid oxidation; disorders of galactose metabolism; disorders of glucose transport; disorders of phenylalanine or tyrosine metabolism; disorders of porphyrin and heme metabolism; fibrous dysplasia/McCune-Albright syndrome; glycogen storage disorders; hypophosphatasia; Kallmann syndrome; lysosomal storage disorders; urea cycle disorders; malignant hyperthermia; or SHOX deficiency disorders.
Clinical presentation and management relevance: The member/enrollee demonstrates clinical features consistent with the suspected disorder, and the testing result will guide management.

Background

This policy addresses genetic testing used to establish or confirm selected nutrition and metabolic disorders. For listed rare disorders, testing may be medically necessary when the member/enrollee demonstrates clinical features consistent with the suspected disorder and the result will guide management. G6PD deficiency can generally be diagnosed using quantitative spectrophotometric analysis or, more commonly, a rapid fluorescent spot test; MTHFR polymorphism testing is not supported for the specified clinical uses.

Definitions

High myopia

Threshold 1Near-sightedness of -6.00 diopters or greater

Threshold 2Axial length greater than 26.5 mm

Marfanoid features or marfanoid habitus

BuildDisproportionately tall and slender

DigitsAbnormally long or slender fingers and toes

SternumProtruding or caving sternum

Eligibility Requirements

MTHFR targeted variant analysis is not supported for evaluating at-risk relatives.

Not Covered

The following testing is not covered: G6PD targeted variant analysis and full-gene sequencing to confirm or establish G6PD deficiency for all indications; and MTHFR targeted variant analysis, including 677T and 1298C testing, for thrombophilia or recurrent pregnancy loss evaluation, at-risk-relative evaluation, or drug metabolism and pharmacogenetic testing.