CurrentBlue Cross Blue Shield - NebraskaPolicy M.79

MA Specialty Testing: Ophthalmology (Preauthorization Required)

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Nebraska Policy M.79 alerts

Get alerted when Policy M.79 changes without checking for updates manually.

Monitor payer policy activity

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

Policy governs preauthorization and medical necessity criteria for genetic and specialty diagnostic testing for inherited and other eye disorders for Blue Cross Blue Shield - Nebraska members.

Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyMA Specialty Testing: Ophthalmology (Preauthorization Required)

Policy CodePolicy M.79

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateJan 1, 2027

Key ActionObtain preauthorization using the quick code search and submit both a procedure and diagnosis code pair before ordering specialty ophthalmology molecular/genetic tests.

SourceLink

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.

CurrentBlue Cross Blue Shield - NebraskaPolicy M.79

MA Specialty Testing: Ophthalmology (Preauthorization Required)

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Nebraska Policy M.79 alerts

Get alerted when Policy M.79 changes without checking for updates manually.

Monitor payer policy activity

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

Policy governs preauthorization and medical necessity criteria for genetic and specialty diagnostic testing for inherited and other eye disorders for Blue Cross Blue Shield - Nebraska members.

Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyMA Specialty Testing: Ophthalmology (Preauthorization Required)

Policy CodePolicy M.79

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateJan 1, 2027

Key ActionObtain preauthorization using the quick code search and submit both a procedure and diagnosis code pair before ordering specialty ophthalmology molecular/genetic tests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3coverage sections

15+min genes (81434)

Not coveredmacular degeneration

~20+molecular CPTs listed

05-01-2026policy effective

Coverage and Medical Necessity Criteria

Inherited Retinal Dystrophies — Multigene panel

Genetic testing via multigene panel may be considered reasonable and necessary when ALL of the following are met:

Inherited retinal dystrophy panel criteria: A. Member has findings consistent with one of the following: (1) Rod-cone degeneration (e.g., retinitis pigmentosa) OR (2) Cone-rod degeneration (e.g., achromatopsia) OR (3) Chorioretinal degeneration OR (4) Macular dystrophy; AND B. The test includes, at a minimum, the RPE65 gene.

Panel must include RPE65; presence of listed clinical phenotype required.

Macular degeneration — Not reasonable/necessary

Policy stance for macular degeneration:

Macular degeneration testing: Genetic testing for macular degeneration is considered not reasonable and necessary for all indications.

Supported by professional guidance noting insufficient evidence that genotyping changes management or guides therapy/supplement recommendations.

Other Covered Eye Disorders — Diagnostic confirmation

Genetic testing may be considered reasonable and necessary to establish or confirm diagnosis when ALL of the following are met:

Other rare eye disorders: Member demonstrates clinical features consistent with one of the following genetically associated eye disorders: Duane syndrome; Familial exudative vitreoretinopathy; Aniridia; X-linked congenital retinoschisis; Presenile cataracts.

List is not exhaustive; other disorders evaluated per the General Approach to Laboratory Testing and disorder-specific clinical features (e.g., GeneReviews, OMIM).

Hereditary Retinal Disorders Panel Coverage

Covered when the hereditary retinal disorders genomic sequencing panel meets the following:

Panel composition requirement: Panel must include sequencing of at least 15 genes.>=15 genes

Panel must include at minimum the 15 specified genes: ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A.

Genetic testing for macular degeneration is explicitly designated as not reasonable and necessary for all indications. Requests for genetic testing to evaluate macular degeneration would therefore be expected to be denied under this policy.

Within the cited sections summarizing other covered eye disorders and code listings, there are no explicit exclusions called out beyond the macular degeneration statement; the document lists covered molecular pathology procedures and individual gene tests but does not enumerate additional exclusionary statements in these chunks.

The policy advises against routine genetic testing for genetically complex disorders such as age-related macular degeneration and late-onset primary open-angle glaucoma until specific genotype-directed treatments or surveillance strategies are proven beneficial in prospective clinical trials. It recommends confining genotyping for these complex disorders to research settings and reserving broad approaches (eg, whole-exome/genome sequencing) for research at tertiary care centers.

In the chunks reviewed there are no explicit statements

Codes and Test Panels

Codes referenced in policy reference tablemixed

81404	Listed in policy reference table
81406	Listed in policy reference table
81408	Listed in policy reference table
81434	Listed in policy reference table
81479	Listed in policy reference table
0205U	Vita Risk (Arctic Medical Laboratories) — listed for macular degeneration
81405	Listed in policy reference table
81400	Listed in policy reference table
81401	Listed in policy reference table
81402	Listed in policy reference table

1–10 of 13
1/2

ICD-10 codes referencedICD-10

H35.50	Retinal degeneration codes range H35.50 - H35.54 listed
H35.30	Macular degeneration codes H35.30 and subcodes listed
Z13.5	Genetic screening code listed

CPT-PLA / Proprietary codesmixed

0205U

OPH AGE-RELATED MAC DEGENERATION ALYS 3 GEN VRNT (analysis of 3 gene variants; buccal swab)

Covered CPT Codes - molecular pathology & panelsCPTCovered

81400	MOLECULAR PATHOLOGY PROCEDURE LEVEL 1
81401	MOLECULAR PATHOLOGY PROCEDURE LEVEL 2
81402	MOLECULAR PATHOLOGY PROCEDURE LEVEL 3
81403	MOLECULAR PATHOLOGY PROCEDURE LEVEL 4
81404	MOLECULAR PATHOLOGY PROCEDURE LEVEL 5
81405	MOLECULAR PATHOLOGY PROCEDURE LEVEL 6
81406	MOLECULAR PATHOLOGY PROCEDURE LEVEL 7
81407	MOLECULAR PATHOLOGY PROCEDURE LEVEL 8
81434	HEREDITARY RETINAL DISORDERS GEN SEQ ANALYSIS 15 GEN
81479	UNLISTED MOLECULAR PATHOLOGY PROCEDURE

1–10 of 11
1/2

Covered CPT Codes / Panel and Unlisted Molecular Pathology CodesCPTCovered

81434	HEREDITARY RETINAL DSORDRS GEN SEQ ANALYS 15 GEN
81479	UNLISTED MOLELCULAR PATHOLOGY PROCEDURE
81599	UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS

Genes specified for hereditary retinal disorders panelmixed

ABCA4	gene listed as included in hereditary retinal disorders panel
CNGA1	gene listed as included in hereditary retinal disorders panel
CRB1	gene listed as included in hereditary retinal disorders panel
EYS	gene listed as included in hereditary retinal disorders panel
PDE6A	gene listed as included in hereditary retinal disorders panel
PDE6B	gene listed as included in hereditary retinal disorders panel
PRPF31	gene listed as included in hereditary retinal disorders panel
PRPH2	gene listed as included in hereditary retinal disorders panel
RDH12	gene listed as included in hereditary retinal disorders panel
RHO	gene listed as included in hereditary retinal disorders panel

1–10 of 15
1/2

Individual full gene sequence tests listedmixedCovered

multiple

Many individual full gene sequence tests are listed (examples include ABCC8, AGL, AHI1, ASPM, CACNA1A, CHD7, COL4A4, COL4A5, COL6A1, COL6A2, COL6A3, CREBBP, F8, JAG1, KDM5C, KIAA0196, L1CAM, LAMB2, MYBPC3, MYH6).

Hereditary retinal disorders panel gene count — inv-16

Minimum gene countPanel must include sequencing of at least 15 genes (>= 15 genes)

Required gene examplesPanel must include, at minimum, genes such as ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, USH2A

CPT mappingCorresponds to CPT 81434 — hereditary retinal disorders genomic sequence analysis panel

Prior Authorization, Ordering, and Documentation

Prior Authorization
Preauthorization required
Preauthorization is required for specialty ophthalmology genetic testing governed by this policy; submit a prior authorization request before performing testing listed in this policy reference table.

Prior Authorization
Preauthorization required for listed molecular/genetic tests
Preauthorization is required for specialty ophthalmology molecular/genetic tests; use the Quick Code Search feature to submit a procedure and diagnosis code pair for review.
Enter the procedure code, then the diagnosis code, then click “Add Code Pair” to determine approval/denial/hold status.

Prior Authorization
Preauthorization required for listed molecular testing codes (e.g., 81434, 81479, 81599)

Background and Scope

Inherited retinal dystrophies encompass disorders such as rod–cone degeneration (retinitis pigmentosa), cone–rod degeneration (achromatopsia), chorioretinal degeneration, and macular dystrophies. Genetic testing using targeted multigene panels can identify actionable genotypes (for example, RPE65) that may affect eligibility for gene-specific therapies; therefore, multigene panel testing is appropriate when the patient’s clinical phenotype matches these inherited retinal dystrophy categories and when panels include required genes.

Definitions and Test Descriptions

Inherited retinal dystrophies — inv-30

Group definitionInherited retinal dystrophies include rod-cone degeneration (e.g., retinitis pigmentosa), cone-rod degeneration (e.g., achromatopsia), chorioretinal degeneration, and macular dystrophy

Clinical implicationMultigene panel testing may be considered when member has findings consistent with one of these phenotypes and panel includes RPE65

Coverage notePanels are reasonable and necessary for diagnostic confirmation of these inherited retinal dystrophies when criteria met

0205U (CPT-PLA) — inv-31

Code and name0205U (CPT-PLA) — OPH AGE-RELATED MAC DEGENERATION ALYS 3 GEN VRNT

Test descriptionAnalysis of 3 gene variants (2 CFH gene, 1 ARMS2 gene) using PCR and MALDI-TOF from a buccal swab; reported as positive or negative for neovascular AMD risk associated with zinc supplements

Policy Revision History

2026-05-01Policy effective

Policy original effective date set.

2026-01-28Last review

Policy last reviewed.

2027-01-01Next reviewLatest

Scheduled next review date.

Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyMA Specialty Testing: Ophthalmology (Preauthorization Required)

Policy CodePolicy M.79

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateJan 1, 2027

Key ActionObtain preauthorization using the quick code search and submit both a procedure and diagnosis code pair before ordering specialty ophthalmology molecular/genetic tests.

SourceLink

On This Page

Preauthorization is required for the molecular testing codes listed in the policy, including CPT 81434, CPT 81479, and CPT 81599; these codes require prior authorization before testing is performed.

81434 — Hereditary retinal disorders genomic sequence analysis panel (must include ≥15 specified genes).
81479 — Unlisted molecular pathology procedure.
81599 — Unlisted multianalyte assay algorithmic analysis.

Step Therapy
Test selection guidance — choose the most specific test and avoid parallel or routine WES/WGS
Order the most specific test(s) available based on the patient’s clinical findings and avoid unnecessary parallel testing; reserve massively parallel strategies (whole-exome or whole-genome sequencing) for research at tertiary care centers.

Prior Authorization
Obtain required prior authorization before testing
Ensure all prior authorization submissions follow the policy’s requirements for procedure/diagnosis pairing and documentation; failure to obtain required authorization may result in denial.

Billing Rule
Submit specific procedure and diagnosis codes for review
When submitting for review, include the specific CPT/proprietary procedure code and the corresponding diagnosis code; use Quick Code Search to confirm whether the code pair is listed in the policy.

Documentation Required
Genetic counseling and written result documentation required
Ensure patients receive counseling from a physician with expertise in inherited disease or a certified genetic counselor and provide the patient with a written copy of genetic test results.

Billing Rule
Quick Code Search entry requires procedure + diagnosis
When using Quick Code Search, providers must enter both a procedure code and a diagnosis code (enter at least the first 3 characters of the diagnosis) to add a code pair for review.
Enter procedure code first, then diagnosis code, then click “Add Code Pair.”
Diagnosis entry requires at least the first 3 characters.

Documentation Required
Document panel composition — ≥15 specified genes required
For hereditary retinal disorder panels, documentation must demonstrate the panel includes sequencing of at least 15 genes (examples: ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, USH2A).

Denial Risk
Denial risk — macular degeneration testing excluded
Genetic testing for macular degeneration is designated not reasonable and necessary for all indications; requests for testing for macular degeneration are expected to be denied.

Denial Risk
Code pair requirement — both procedure and diagnosis required
Quick Code Search/code pair submissions require both a procedure and a diagnosis; missing either element may prevent approval or initiate review and delay processing.

Prior Authorization
Preauthorization required (policy header) — lack of prior auth may lead to denial
This policy requires preauthorization for specialty ophthalmology genetic and molecular testing; performing tests without prior authorization may result in claim denial.

Indication noteProprietary ophthalmology AMD 3-variant test — associated with age-related macular degeneration risk assessment

81434 — inv-32

CPT code81434 — HEREDITARY RETINAL DISORDERS GEN SEQ ANALYSIS 15 GEN

DefinitionGenomic sequence analysis panel for hereditary retinal disorders that must include sequencing of at least 15 genes

Examples of included genesIncludes ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, USH2A

Hereditary retinal disorders genomic sequence analysis panel (CPT 81434) — inv-33

Panel requirementHereditary retinal disorders genomic sequence analysis panel must include sequencing of at least 15 genes

Representative gene listABCA4; CNGA1; CRB1; EYS; PDE6A; PDE6B; PRPF31; PRPH2; RDH12; RHO; RP1; RP2; RPE65; RPGR; USH2A

Associated conditionsIntended for disorders such as retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy