Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesGenetic & Molecular TestingAmbetter Nevada MODY Testing Coverage | OpenPayer
    Ask Trek AI about this page
    CurrentAmbetter NevadaPolicy N/A

    Concert Genetic Testing: Endocrinology

    Customize your policy alerts

    Sign up for all Ambetter Nevada policy alerts

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

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This policy governs medical-necessity criteria for genetic testing used to establish or confirm monogenic diabetes, including maturity-onset diabetes of the young (MODY), for Ambetter Nevada members. It also provides coding references and advises pre-test and post-test genetic counseling.

    Policy Summary
    PayerAmbetter Nevada
    PolicyConcert Genetic Testing: Endocrinology
    Policy CodePolicy N/A
    Change TypeNo material clinical or coverage changes
    Effective DateMay 1, 2026
    Last ReviewNov 1, 2025
    Next Review DateN/A
    Key ActionDocument diabetes diagnosis timing or age, phenotype, applicable laboratory findings, and relevant family history before ordering testing.
    SourceLink
    POLICY UPDATE CHANGES

    The policy was created as a separate endocrinology policy from the former Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders policy.

    The statement for indications outside the listed monogenic diabetes criteria was changed from an investigational statement to language stating that current evidence does not support testing.

    Criteria for known familial variant analysis were moved to the General Approach to Genetic and Molecular Testing policy.

    12 monthsEarliest-life diabetes diagnosis pathway

    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.

    <30 yearsAge-based testing pathway
    2Qualifying clinical pathways
    1Testing service category

    Coverage Criteria

    Monogenic diabetes and MODY panel testing

    Multigene panel analysis to establish or confirm a diagnosis of monogenic diabetes, including maturity-onset diabetes of the young (MODY), is medically necessary when at least one qualifying pathway is met.

    Qualifying clinical pathway

    • Pathway A: The member/enrollee has a diagnosis of diabetes within the first 12 months of life.within the first 12 months of life

    • Pathway B

      • Supporting finding

        • Autoantibody status: Autoantibody negative.negative
        • C-peptide status: Retained C-peptide levels.retained

    • Pathway C

      • Atypical diabetes: Diagnosis of diabetes not characteristic of type 1 or type 2 diabetes.
      • Family history of diabetes consistent with an autosomal dominant pattern of inheritance.autosomal dominant pattern of inheritance

    Other indications

    Current evidence does not support testing for all other indications.

    Unsupported indications: Multigene panel analysis to establish or confirm a diagnosis of monogenic diabetes, including MODY, is not supported for indications other than the qualifying pathways listed in this policy.

    Multigene panel analysis for monogenic diabetes, including maturity-onset diabetes of the young (MODY), is not supported by current evidence when the indication falls outside the qualifying clinical pathways described in this policy.

    Testing is not medically necessary when the member does not meet the applicable age, clinical phenotype, laboratory finding, or family-history requirements. Qualifying evidence may include diabetes diagnosed within the first 12 months of life, diabetes diagnosed before 30 years of age with autoantibody-negative status or retained C-peptide levels, or atypical diabetes with a qualifying family history.

    Qualifying Clinical Pathways

    Diabetes diagnosed within the first 12 months of life

    Testing is medically necessary under this pathway when the diagnosis was made within the specified period.

    Early-onset diabetes: The member/enrollee has a diagnosis of diabetes within the first 12 months of life.within the first 12 months of life

    Atypical diabetes with autosomal dominant family history

    Both the atypical diabetes phenotype and the qualifying family history must be present.

    • Atypical diabetes: Diagnosis of diabetes not characteristic of type 1 or type 2 diabetes.

    Eligibility Requirements

    For the atypical-diabetes pathway, the member must have diabetes that is not characteristic of type 1 or type 2 diabetes and a family history consistent with an autosomal dominant pattern of inheritance. Both the atypical diabetes presentation and the qualifying family history are required.

    Noncovered Indications

    Monogenic diabetes or MODY multigene panel testing is not supported by current evidence for indications outside the policy’s qualifying clinical pathways.

    Coding References

    Monogenic Diabetes (Including Maturity Onset Diabetes of the Young (MODY)) Panels, 1mixed
    Maturity Onset Diabetes of the Young (MODY) Panel (PreventionGenetics, part of Exact Sciences)Maturity Onset Diabetes of the Young (MODY) Panel (PreventionGenetics, part of Exact Sciences)
    Maturity-onset diabetes of the young (MODY) (Ambry Genetics)Maturity-onset diabetes of the young (MODY) (Ambry Genetics)
    Monogenic Diabetes (MODY) Five Gene EvaluationMonogenic Diabetes (MODY) Five Gene Evaluation
    Monogenic Diabetes (Including Maturity Onset Diabetes of the Young (MODY)) Panels, 2mixed
    8140381403
    8140581405
    8140681406
    8140781407
    8147981479
    E10E10
    E11E11
    E16.1E16.1
    Monogenic Diabetes (Including Maturity Onset Diabetes of the Young (MODY)) Panels, 3mixed
    11
    22
    55
    Age at diabetes diagnosis
    Age thresholdWithin the first 12 months of life
    Qualifying pathwayDiagnosis of diabetes within the first 12 months of life
    Coverage applicationSupports medical necessity for multigene panel analysis to establish or confirm monogenic diabetes, including MODY
    Age at diabetes diagnosis
    Age thresholdBefore 30 years of age
    Required supporting findingAt least one of the following: autoantibody negative or retained C-peptide levels

    Provider Documentation and Counseling

    Documentation Required

    Document qualifying clinical features

    Support the clinical record with the diabetes diagnosis timing or age, whether the diabetes is characteristic of type 1 or type 2 diabetes, autoantibody status or retained C-peptide when applicable, and family history consistent with autosomal dominant inheritance when applicable.

    • Document diabetes diagnosed within the first 12 months of life, or before 30 years of age when applicable.
    • Record autoantibody-negative status or retained C-peptide levels when applicable.
    • For atypical diabetes, document a family history consistent with an autosomal dominant pattern of inheritance.
    Denial Risk

    Confirm the indication meets policy criteria

    Multigene panel analysis to establish or confirm monogenic diabetes, including MODY, is not supported by current evidence when the member does not meet one of the policy’s qualifying clinical pathways.

    Clinical Background

    Monogenic diabetes comprises inherited forms of diabetes, including maturity-onset diabetes of the young (MODY), that may not fit typical type 1 or type 2 diabetes patterns. Genetic testing may establish or confirm the diagnosis in people with very early-onset diabetes, atypical diabetes, or findings suggesting an inherited autosomal dominant disorder.

    Key Definitions

    Monogenic diabetes panel
    DefinitionA multigene panel analysis used to establish or confirm a diagnosis of monogenic diabetes, including maturity-onset diabetes of the young (MODY)
    Policy scopeThe panel is addressed for monogenic diabetes, including MODY
    Medical-necessity useTesting is medically necessary when a qualifying clinical pathway is met
    MODY
    Full termMaturity-onset diabetes of the young
    Clinical definitionAn inherited diabetes presentation associated with diabetes that is not characteristic of type 1 or type 2 diabetes
    Family pattern
    Policy Summary
    PayerAmbetter Nevada
    PolicyConcert Genetic Testing: Endocrinology
    Policy CodePolicy N/A
    Change TypeNo material clinical or coverage changes
    Effective DateMay 1, 2026
    Last ReviewNov 1, 2025
    Next Review DateN/A
    Key ActionDocument diabetes diagnosis timing or age, phenotype, applicable laboratory findings, and relevant family history before ordering testing.
    SourceLink
    On This Page
    Coverage CriteriaQualifying Clinical PathwaysEligibility RequirementsNoncovered IndicationsCoding ReferencesProvider Documentation and CounselingClinical BackgroundKey Definitions
    Family history of diabetes consistent with an autosomal dominant pattern of inheritance.
    autosomal dominant pattern of inheritance
    Coverage applicationThe age threshold and at least one supporting finding are required for this qualifying pathway
    • Qualifying pathways include diabetes diagnosed within the first 12 months of life.
    • A diagnosis before 30 years of age must include autoantibody-negative status or retained C-peptide levels.
    • Atypical diabetes must include a family history consistent with an autosomal dominant pattern of inheritance.
    Note

    Arrange genetic counseling

    Pre-test and post-test genetic counseling is strongly advised to facilitate informed decision-making, address possible secondary or incidental findings, and establish a plan for returning results before testing occurs.

    May be associated with a family history of diabetes consistent with an autosomal dominant pattern of inheritance