Document abnormal iron studies or family history for HFE genotyping

HFE C282Y and H63D genotyping requires documentation of abnormal iron studies indicating iron overload (e.g., elevated transferrin‑iron saturation and/or elevated serum ferritin) or documentation of a first‑degree relative with hereditary hemochromatosis.

• 81256

Document pancreatitis history for hereditary pancreatitis panels

Hereditary pancreatitis multigene panel coverage requires documentation of a personal history of pancreatitis plus at least one qualifying feature such as unexplained childhood acute pancreatitis, recurrent (≥2) unexplained acute attacks, chronic unexplained pancreatitis with onset <35 without heavy alcohol use, or a close relative with similar pancreatitis history.

• 81222
• 81223
• 81404
• 81405
• 81479

Document age of onset and qualifying features for hereditary IBD panels

Hereditary IBD/Crohn's multigene testing requires documentation of infantile‑onset IBD (<2 years) or very early‑onset IBD (<6 years) plus at least one additional qualifying feature (e.g., congenital multiple intestinal atresias, congenital diarrhea, malignancy <25, inborn error of immunity features, complex autoimmune features, a close relative meeting criteria, stem cell transplant candidate, or history of multiple intestinal resections).

• 81321
• 81406
• 81407
• 81479

FIB-4 and test interval requirements for noninvasive liver tests

Blood‑based noninvasive liver disease algorithmic tests are allowed only when there is no confirmed liver fibrosis, the same test has not been performed within the past year, a qualifying liver indication is documented (untreated chronic HCV or suspected/confirmed MASLD), and the FIB‑4 score meets the policy thresholds; for low FIB‑4 with metabolic risk, document prediabetes/type 2 diabetes or ≥2 metabolic syndrome features.

• 81517
• 81596
• 0003M
• Requirements: The member does NOT have a confirmed diagnosis of liver fibrosis.
• Requirements: The test has NOT been performed within the last year.
• Requirements: Document liver disease indication (untreated chronic HCV infection OR suspected/confirmed MASLD).
• Requirements: FIB-4 thresholds — >=1.3 for individuals <65 years; >=2.0 for individuals >=65 years (intermediate/high risk); <1.3 for <65 and <2.0 for >=65 considered low risk.
• Requirements: For low FIB-4 with metabolic risk, document prediabetes/type 2 diabetes OR two or more features of metabolic syndrome.

Prior testing requirement for HLA-DQ genotyping

HLA‑DQA1 and HLA‑DQB1 genotyping analysis must not have been previously performed for the added coverage criterion to apply.

• HLA‑DQA1/DQB1 genotyping must not have been previously performed.

Consolidation of known familial variant testing

Known familial variant analysis criteria for gastroenterologic conditions have been moved to the separate policy 'Genetic Testing: General Approach to Genetic and Molecular Testing'; providers should reference that policy for preauthorization and documentation requirements for known familial variant testing.