Use listed CPT/HCPCS codes for authorization and billing

Reference the policy's listed molecular/CPT codes when requesting coverage or prior authorization for cardiovascular multigene panels; example CPT and ICD codes include 81439, 81413, 81414, 81403, 81406, 81407, 81401, 81405, 81404, 81408, 81410, 81411, 0237U, 0493U and associated ICD-10 examples (e.g., I42.x, I45.81, E78.01, Z13.71, Z82.41). Use the appropriate panel code when a panel is performed.

• Examples of comprehensive cardiomyopathy panel billing codes include 81439 and related ICD-10 codes (I42.0, I42.1, I42.2, I42.5, I42.8, I42.9).
• Arrhythmia panels examples include 81413, 81414, 0237U and relevant ICD-10 codes (I45.81, I49.8).
• FH and other panels list CPTs such as 81401, 81405, 81408, 81410, 81411 and ICD group examples (E78 / E78.01).
• Reference-table additions include Prospera (0493U) for donor-derived cell-free DNA in transplant contexts.

Prior authorization required for multigene panels unless criteria documented

Obtain prior authorization when ordering multigene panels unless the patient's medical record already documents that the specific medical necessity criteria for the relevant panel are met (e.g., criteria for HCM, DCM, ACM, LQTS, Brugada, FH).

• Prior authorization applies to comprehensive cardiomyopathy and arrhythmia panels and to condition-specific panels unless chart documentation satisfies the panel-specific criteria.
• If a panel is performed, ensure the appropriate panel code is used on the authorization request.

HHT panel: require clinical features and ACVRL1/ENG on panel

Order HHT multigene panel testing only when the member has clinical features of HHT and the panel includes at minimum ACVRL1 and ENG; document the qualifying clinical features.

• Clinical features qualifying for HHT testing include spontaneous recurrent epistaxis, mucocutaneous telangiectases at characteristic sites, or visceral AVMs (pulmonary, cerebral, spinal, gastrointestinal, pancreatic).
• Panel must include at least ACVRL1 and ENG to meet medical necessity.

Include required clinical findings and family history with prior authorization

Supply panel-specific clinical documentation with prior authorization requests — ordering clinicians must demonstrate the diagnostic findings and family history specified for the requested panel (e.g., LV wall thickness ≥15 mm or pediatric z-score ≥2 for HCM; EF <50% for DCM; QTc thresholds or Schwartz score for LQTS).

• HCM: document myocardial wall thickness ≥15 mm in adults or z-score ≥2 in children on echo or cardiac MRI.
• DCM: document LV enlargement/biventricular dilatation plus systolic dysfunction (EF <50%) and exclusion of non-genetic causes.
• LQTS/SQTS: document QTc thresholds or Schwartz/SQTS diagnostic scores as applicable.

Prior authorization for transplant-related tests (e.g., Prospera 0493U)

Obtain prior authorization for transplant-related molecular tests per policy reference table — donor-derived cell-free DNA (e.g., Prospera 0493U) and post-transplant gene expression panels have specific coverage notes and may require prior authorization.

• Prospera (0493U) is listed in the policy reference table for donor-derived cell-free DNA.
• Post–heart-transplant gene expression panels (blood or tissue) have distinct coverage notes and default monitoring frequency guidance.

Prior authorization decisions follow Health Plan and regulatory policies

Recognize that final prior authorization and coverage decisions are governed by the Health Plan's administrative policies and may require review of applicable Medicare NCDs/LCDs; follow plan-level procedures when submitting authorization requests.

• This clinical policy guides medical necessity determinations but does not guarantee payment; coverage is subject to plan terms and state/federal requirements.
• Medicare members may require review of applicable NCDs/LCDs prior to coverage determination.

Route known familial variant testing per the general genetic testing policy

When a known familial variant is suspected, follow the consolidated General Criteria for Known Familial Variant Analysis in the organization's general genetic testing policy rather than requesting familial variant testing under this cardiac panels policy.

• Known familial variant analysis criteria were moved to the General Approach to Genetic and Molecular Testing policy; requests not following that consolidated policy may be denied.

Prefer multigene panels over serial single-gene testing; follow combined-panel rules

Prefer multigene panels over serial single-gene testing for genetically heterogeneous cardiomyopathies and, when both individual panel and combined panel criteria apply, ensure the member meets criteria for the combined test per policy.

• Guidelines recommend testing the most clearly affected family member first and cascade testing of pathogenic/likely pathogenic variants.
• If member meets criteria for both cardiomyopathy and arrhythmia panels, the combined comprehensive panel is medically necessary only when both criteria sets are met.

Preferred initial approach: phenotype-focused multigene panels (FH, HTAD/TAAD)

Use a multigene panel as the preferred initial testing approach for certain conditions (e.g., FH panels should include LDLR, APOB, PCSK9; HTAD/TAAD evaluation should use a multigene HTAD panel) rather than incremental single-gene testing.

• FH panels should at minimum include LDLR, APOB, and PCSK9 and include LDLR deletion/duplication analysis.
• TAAD/HTAD evaluation: a multigene panel that includes known HTAD genes is recommended as first-line testing.

Document provision of genetic counseling and expert consultation

Ensure pre-test and post-test genetic counseling and involvement of or consultation with a cardiac genetics expert for testing decisions and interpretation; document counseling and rationale in the medical record.

• Genetic counseling is strongly advised to facilitate informed decision-making and address incidental findings.
• Testing decisions and interpretation should be performed by or in consultation with a cardiac genetics expert.

Document required diagnostic findings and thresholds to support testing

Document the specific required clinical findings in the medical record to support medical necessity for the requested panel (examples: LV wall thickness ≥15 mm or pediatric z-score ≥2 for HCM; EF <50% for DCM; specific ECG/Schwartz or QTc thresholds for LQTS/SQTS; LDL-C thresholds for FH).

• HCM: myocardial wall thickness ≥15 mm in adults or z-score ≥2 in children (echo or cardiac MRI).
• DCM: LV enlargement/biventricular dilatation plus systolic dysfunction (EF <50%) and exclusion of secondary causes.
• LQTS: QTc >460 ms (prepuberty) or >480 ms (adults) or Schwartz score ≥3.0 for symptomatic patients.
• SQTS: QTc ≤330 ms or SQTS diagnostic score ≥4 when applicable.
• FH: at least two elevated LDL-C measurements and specified LDL-C thresholds per age and family history.

Document multidisciplinary review and sample collection for SCA/SUD cases

For SCA/SUD evaluations, document multidisciplinary team involvement, detailed phenotype, and that samples suitable for future DNA testing were collected and stored; when phenotype is known, document the targeted candidate genes considered.

• A comprehensive autopsy and storage of tissue suitable for genetic analysis should be documented when relevant.
• Genetic investigation should focus on likely candidate genes consistent with the suspected phenotype and be performed in a multidisciplinary center when possible.

Provide comprehensive clinical documentation and prior test results with orders

Include clinical diagnostic criteria, diagnostic scores, ECG findings, family history, and records of prior non-diagnostic evaluations (e.g., exclusion of reversible, ischemic, or structural causes) when submitting testing requests to support medical necessity.

• Provide ECG recordings free of modifiers that shorten QT when applicable and document measurement method for intervals.
• Document prior cardiac testing (ECG, stress tests, echocardiogram, imaging) and exclusion of reversible causes when ordering arrhythmia panels.

Document transplant status; default routine monitoring coverage = once per 12 months

For routine post‑transplant molecular monitoring, adhere to policy guidance that absent specific guideline regimens the default covered frequency is once every 12 months; document transplant status and indication for surveillance testing.

• Post-heart-transplant gene expression panels for rejection risk (blood or tissue) have specific criteria; document transplant history when requesting surveillance testing.
• Default coverage frequency for routine monitoring is once every 12 months unless guideline-based regimens specify otherwise.

Denial risk: failure to meet panel-specific medical necessity criteria

Be aware that testing may be denied if the member does not meet the specific medical necessity criteria listed for comprehensive cardiomyopathy, arrhythmia, combined, or other condition‑specific panels; do not order comprehensive or combined panels outside the enumerated indications.

• Comprehensive cardiomyopathy/arrhythmia/combined panels are medically necessary only when the policy's explicit criteria are met; otherwise testing may be denied.
• Review the panel-specific criteria before ordering to avoid noncoverage.

Denial risk: combined comprehensive panels limited to dual-criteria cases

Order comprehensive combined cardiomyopathy+arrhythmia panels only when the member meets both the Comprehensive Cardiomyopathy Panels and Comprehensive Arrhythmia Panels clinical criteria; otherwise the combined panel is not supported.

• Combined panels that include genes for both conditions are medically necessary only when both sets of criteria are satisfied.

Denial risk: unfocused/hypothesis-free genetic testing discouraged for SCD/SCA without phenotype

Do not order large unfocused gene panels, WES, or WGS for sudden cardiac death cases without a definable clinical phenotype — hypothesis-free testing in that setting is discouraged and may not be supported for routine care.

• Hypothesis-free genetic testing should be considered only in research contexts; routine patient care requires phenotype-focused testing.

Denial risk: gene selection limited when gene‑disease validity is disputed

Expect tests to be limited or modified when gene-disease validity is disputed (for example, reporting genes other than SCN5A for Brugada is discouraged); ordering inappropriate gene sets may result in denial or noncoverage.

• For Brugada syndrome, SCN5A is identified as the gene with strongest diagnostic validity; other genes with disputed ClinGen status are discouraged for diagnostic reporting.
• Testing panels that include genes with disputed validity may be limited or considered not medically necessary.

Denial risk: known familial variant testing must follow consolidated general policy

Follow the general policy for known familial variant analysis — requests that do not follow the consolidated general criteria for familial variant testing may be denied.

• Known familial variant testing criteria were moved to the General Approach to Genetic and Molecular Testing; use that policy's process for familial variant analysis.

Coverage decision dependencies: follow plan documents and regulatory requirements

Recognize coverage decisions depend on plan terms, exclusions, state/federal requirements, and Health Plan administrative policies; review applicable coverage documents when planning testing and prior authorization.

• This policy guides medical necessity determinations but coverage and payment remain subject to plan documents and legal/regulatory requirements.
• When state Medicaid provisions conflict with this policy, state Medicaid rules take precedence.