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    v1.0.28
    OpenPayerPolicy UpdatesGenetic & Molecular TestingAmbetter Nevada Hearing Loss Coverage | OpenPayer
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    CurrentAmbetter NevadaPolicy N/A

    Concert Genetic Testing: Otolaryngology

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    This policy governs medical-necessity criteria for genetic tests used to identify hereditary hearing loss and other ear, nose, and throat disorders for Ambetter Nevada members/enrollees.

    Policy Summary
    PayerAmbetter Nevada
    PolicyConcert Genetic Testing: Otolaryngology
    Policy CodePolicy N/A
    Change TypeMinor rewordingno clinical evidence changes
    Effective DateMay 1, 2026
    Next Review DateN/A
    Key ActionConfirm hearing loss has no known acquired cause before ordering covered GJB2/GJB6 or multigene panel testing.
    SourceLink
    POLICY UPDATE CHANGES

    The policy title was changed from Concert Genetic Testing: Hearing Loss to Concert Genetic Testing: Otolaryngology.

    2Primary genes addressed
    2Required clinical criteria
    5CPT codes listed

    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.

    3Excluded acquired causes

    Coverage Criteria

    GJB2/GJB6 sequencing, deletion/duplication, or multigene panel analysis

    Covered as medically necessary when all of the following criteria are met:

    Hereditary hearing-loss testing

    • Test approach

      • GJB2 sequencing and/or deletion/duplication analysis.
      • GJB6 sequencing and/or deletion/duplication analysis.
      • Multigene panel analysis.
    • Hearing loss: The member/enrollee has hearing loss.
    • No known acquired cause: There is no known acquired cause of the hearing loss, including TORCH infections, bacterial infection, age-related hearing loss, or noise-related hearing loss.

    Other indications

    Not supported for indications outside the specified hereditary hearing-loss criteria.

    Unsupported indications: Current evidence does not support GJB2 sequencing and/or deletion/duplication analysis, GJB6 sequencing and/or deletion/duplication analysis, or multigene panel analysis to establish a diagnosis of hereditary hearing loss for all other indications.

    Testing is not supported when the member/enrollee has a known acquired cause of hearing loss, including TORCH infections, bacterial infection, age-related hearing loss, or noise-related hearing loss.

    GJB2/GJB6 sequencing or deletion/duplication analysis and multigene panel analysis are not supported for indications other than establishing a diagnosis of hereditary hearing loss under the specified criteria.

    Covered Indications

    Establishing a diagnosis of hereditary hearing loss in a member/enrollee with hearing loss and no known acquired cause

    Covered test approaches include the following when establishing a diagnosis of hereditary hearing loss:

    Covered indication

    • Test approach

      • GJB2 sequencing and/or deletion/duplication analysis.
      • GJB6 sequencing and/or deletion/duplication analysis.
      • Multigene hearing-loss panel analysis.

    • Clinical criteria

    Coding Information

    Common billing codes for hereditary hearing-loss testingCPT
    81252Referenced in the policy reference table for hereditary hearing-loss genetic testing
    81479Referenced in the policy reference table for hereditary hearing-loss genetic testing
    81254Referenced in the policy reference table for hereditary hearing-loss genetic testing
    81430Referenced in the policy reference table for hereditary hearing-loss genetic testing
    81431Referenced in the policy reference table for hereditary hearing-loss genetic testing
    Common diagnosis codes for hereditary hearing-loss testingICD-10
    H90-H90.8Hearing-loss diagnosis code range referenced in the policy reference table
    H90.A-H90.A3Hearing-loss diagnosis code range referenced in the policy reference table
    H91.3-H91.93Hearing-loss diagnosis code range referenced in the policy reference table

    Provider Actions

    Denial Risk

    Known acquired cause: testing not supported

    Do not submit GJB2/GJB6 sequencing, deletion/duplication analysis, or multigene panel analysis under the specified hereditary hearing-loss criteria when a known acquired cause of hearing loss is present.

    • Examples include TORCH infections, bacterial infection, age-related hearing loss, and noise-related hearing loss.
    Denial Risk

    Other indications are not supported

    Current evidence does not support GJB2/GJB6 sequencing, deletion/duplication analysis, or multigene panel analysis to establish a diagnosis of hereditary hearing loss for indications other than the specified criteria.

    Note

    Advise genetic counseling before and after testing

    Clinical Background

    Hereditary hearing loss is genetically heterogeneous. The DFNB1 locus, which contains GJB2 and GJB6, accounts for an estimated 50% of autosomal-recessive nonsyndromic hearing loss and approximately 15% to 40% of deaf individuals in various populations.

    Not Covered

    The following are not covered for indications other than the specified hereditary hearing-loss criteria: GJB2/GJB6 sequencing or deletion/duplication analysis and multigene panel analysis.

    Policy Summary
    PayerAmbetter Nevada
    PolicyConcert Genetic Testing: Otolaryngology
    Policy CodePolicy N/A
    Change TypeMinor rewordingno clinical evidence changes
    Effective DateMay 1, 2026
    Next Review DateN/A
    Key ActionConfirm hearing loss has no known acquired cause before ordering covered GJB2/GJB6 or multigene panel testing.
    SourceLink
    On This Page
    Coverage CriteriaCovered IndicationsCoding InformationProvider ActionsClinical BackgroundNot Covered
    The member/enrollee has hearing loss.
  1. There is no known acquired cause of the hearing loss, including TORCH infections, bacterial infection, age-related hearing loss, or noise-related hearing loss.

    2. Strongly advise pre-test and post-test genetic counseling before testing to facilitate informed decision-making, address possible secondary or incidental findings, and establish a plan for returning results.