Preauthorization required

Preauthorization is required for MA Specialty Testing: Cardiovascular. When a National Coverage Determination (NCD) or Local Coverage Determination (LCD) exists it will be applied first; when no CMS guideline applies this policy governs preauthorization decisions.

• Obtain prior authorization before ordering specialty cardiovascular genetic testing.
• If an NCD/LCD applies, follow that determination first; otherwise follow this policy.

Preauthorization required for listed panels and single‑gene tests

Preauthorization must be obtained for the listed cardiovascular multigene panels and single-gene analyses. Requests must document that the member meets the condition‑specific clinical criteria described in this policy.

• Include clinical findings that satisfy the specific criteria for the panel or single‑gene test (e.g., imaging thresholds, ECG findings, family history).
• Use the appropriate panel code when a panel is performed.

Seek prior authorization for phenotype‑focused panels

Preauthorization should be requested for phenotype‑directed comprehensive cardiomyopathy or arrhythmia panels when guideline‑based indications are present (for example, a clearly affected proband, survivors of SCA, or relatives of SUD/SCD cases).

• Phenotype‑directed testing is preferred over hypothesis‑free testing.
• Collect and document phenotype information and, when applicable, autopsy tissue suitable for DNA storage.

Prior authorization required for listed panel codes

Selected panel and molecular CPT/CPT‑PLA codes listed in the policy (for example 0237U for a cardiac ion channelopathies panel) are subject to the payer's prior authorization processes and must be submitted through the Quick Code Search/code pair tool.

• Enter the procedure code (e.g., 0237U) when submitting the authorization request.
• Ensure the panel code used matches the test performed and gene content when required.

Preauthorization required for listed molecular pathology and panel codes

Preauthorization is required for specialty cardiovascular molecular testing using the CPT/CPT‑PLA and molecular pathology codes listed in the policy (examples include 81413–81414, 81439, 81401, 81407, 0237U). Gene‑panel composition must be documented on the request when specified.

• Provide the CPT or CPT‑PLA code from the policy when requesting authorization.
• If the policy specifies gene content for a panel, include gene‑content information on the request (e.g., cardiac ion channelopathies panels must include ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, SCN5A).

Policy within MA Specialty Testing preauthorization program

This policy is part of the MA Specialty Testing: Cardiovascular preauthorization program; testing for the conditions and codes addressed may require preauthorization as described in this policy.

• Follow the MA Specialty Testing program procedures when requesting authorization.
• Policies do not constitute guarantee of payment—benefit terms determine coverage.

Provider responsibilities for authorization and counseling

Providers must follow the policy's preauthorization and documentation requirements when ordering specialty cardiovascular genetic testing.

• Ensure testing decisions and interpretation involve or consult a cardiac genetics expert.
• Obtain pre‑test and post‑test genetic counseling when possible.

Brugada testing: SCN5A single‑gene only when criteria met

For suspected Brugada syndrome, single‑gene analysis of SCN5A is acceptable when the policy criteria are met; testing of other genes or multigene panels for Brugada is explicitly considered not reasonable and necessary.

• SCN5A testing covered when ECG criteria, exclusion of phenocopies, and clinical features (e.g., syncope, VF, family history) are documented.
• Do not order multigene Brugada panels or other BrS genes for diagnostic testing per policy.

Prefer multigene panels for heterogeneous cardiomyopathies; avoid unfocused testing

For heterogeneous cardiomyopathies, multigene panels are preferred over serial single‑gene testing; unfocused large panels, whole‑exome, or whole‑genome sequencing without a defined phenotype are discouraged for routine care.

• Order a phenotype‑directed multigene panel for cardiomyopathy when the member meets diagnostic criteria.
• Avoid hypothesis‑free or very large unfocused panels unless part of a research effort.

No step therapy required when CPVT or SQTS criteria are met

When diagnostic criteria for CPVT or SQTS are met (per guideline diagnostic criteria or SQTS diagnostic score), molecular genetic testing is recommended; the policy does not require prior step‑therapy sequencing before testing.

• If CPVT or SQTS diagnostic criteria are satisfied, proceed with recommended molecular testing.
• No step‑therapy or prior incremental sequencing steps are specified in the policy.

Genetic counseling and cardiac genetics expertise recommended

Providers should ensure testing requests include genetic counseling involvement and, when appropriate, consultation with cardiac genetics experts for test selection and interpretation.

• Document that pre‑test and post‑test genetic counseling was provided or offered.
• Consult a cardiac genetics expert for interpretation when results are complex.

Use correct panel code and document clinical criteria

If a panel is performed, use the appropriate panel CPT/CPT‑PLA code and document that the member meets the clinical criteria for the requested panel as specified in the policy.

• Select the panel code that corresponds to the test and include condition‑specific clinical evidence that meets policy criteria.
• Failure to use the appropriate code and document criteria may delay authorization.

Provide required clinical documentation with requests

Include detailed clinical documentation with the preauthorization request: phenotype description, personal and family history, ECGs, imaging results, and specimen details if available (for example, autopsy tissue or prior genetic test results).

• Attach ECG tracings and imaging reports that demonstrate the diagnostic measurements described in the policy (e.g., LV wall thickness, EF, RVOT dimensions).
• Provide family history and any prior molecular testing results.

SQTS documentation required for authorization

When requesting SQTS testing, include ECG findings (QTc and J‑point–Tpeak interval), clinical history, family history, and the SQTS diagnostic score elements when available to demonstrate that diagnostic criteria are met.

• Document baseline ECG without modifiers that shorten QT.
• Provide calculated SQTS diagnostic score or component elements.

Document Brugada phenotype and exclusion of phenocopies

For Brugada syndrome testing, document compatible clinical features (e.g., recurrent syncope, ventricular arrhythmia, family history), the EKG pattern (Type 1 or provoked Type 1), and exclusion of phenocopies such as ischemia, electrolyte disturbance, or drug intoxication.

• Attach ECG demonstrating Type 1 or provoked Type 1 pattern when available.
• State that phenocopies have been excluded and provide supporting data.

Include panel code and gene‑content on preauthorization

When submitting preauthorization for cardiac genetic panels include the specified panel CPT/CPT‑PLA codes (for example 0237U) and indicate gene‑content when required (for example cardiac ion channelopathies panels must include at least ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, SCN5A).

• List the exact CPT or CPT‑PLA code used for the test on the authorization request.
• If policy requires minimum gene content for a panel, include the gene list or laboratory gene content statement.

Ensure documentation aligns with benefit terms

Medical policies reference CPT codes and are used to administer plan benefits; providers should ensure documentation submitted for authorization aligns with the applicable benefit contract and policy guidance.

• Policies do not guarantee payment — benefits are determined by the member's contract.
• Ensure submitted documentation matches policy requirements to reduce risk of denial.

NCD/LCDs applied first; missing authorization may trigger denial

If an NCD or LCD exists it will be applied before this policy; absence of required preauthorization or failure to meet policy criteria may result in denial of the request.

• Check for applicable NCDs/LCDs prior to submission.
• Obtain required preauthorization and document clinical criteria to avoid denials.

HCM panel denial trigger — insufficient LVH evidence

Genetic testing for HCM via multigene panel is not reasonable and necessary for indications other than unexplained LV hypertrophy defined by myocardial wall thickness ≥15 mm in adults (or z‑score ≥2 in children).

• Provide imaging demonstrating LV wall thickness ≥15 mm (adults) to support medical necessity.
• Requests for HCM panels outside these criteria are likely to be denied.

DCM panel denial trigger — does not meet DCM criteria

Genetic testing for DCM via multigene panel is not reasonable and necessary for indications that do not meet the listed DCM criteria, including left ventricular enlargement, systolic dysfunction (EF <50%), and exclusion of non‑genetic causes.

• Document LV enlargement and EF <50% on imaging and that non‑genetic causes have been ruled out.
• Requests lacking these elements may be denied.

Arrhythmogenic cardiomyopathy panel denial trigger

Genetic testing for arrhythmogenic cardiomyopathy via multigene panel is not reasonable and necessary for indications other than the specified Task Force major/minor diagnostic criteria combinations described in the policy.

• Provide diagnostic Task Force criteria measurements or findings (imaging, ECG, biopsy) when requesting testing.
• Requests that do not meet Task Force criteria are at risk for denial.

LQTS panel denial trigger — does not meet ECG/Schwartz criteria

LQTS multigene panel testing is not reasonable and necessary for indications other than the defined ECG/proband criteria or symptomatic presentations with cardiologist suspicion or Schwartz score thresholds; non‑genetic causes must be excluded.

• Document prolonged QTc by age‑appropriate thresholds (>460 ms prepuberty; >480 ms adults) or cardiologist assessment/Schwartz score ≥3.
• Exclude reversible causes of QT prolongation in the documentation.

Brugada testing denial trigger — criteria not met

SCN5A variant analysis for Brugada syndrome (codes 81407, S3861) is not reasonable and necessary for indications other than the specified ECG phenotype, exclusion of phenocopies, and clinical features required by policy.

• Provide Type 1 (or provoked Type 1) ECG documentation, evidence phenocopies are excluded, and relevant clinical features (e.g., syncope, VF, family history).
• Requests for SCN5A testing lacking these elements may be denied.

Unfocused panel risk — avoid hypothesis‑free testing without phenotype

Use of large unfocused gene panels or hypothesis‑free testing (including whole‑exome or whole‑genome sequencing) in the absence of a clinical phenotype is discouraged and not recommended for routine patient care; such unfocused testing may not meet clinical applicability criteria and risk denial.

• Order phenotype‑directed panels rather than broad unfocused panels when no phenotype is identified.
• Requests for hypothesis‑free testing may be denied as not medically necessary.

Procedure/diagnosis code pairing required for Quick Code Search

Enter both a procedure and diagnosis code pair when using the Quick Code Search; absence of an appropriate code pair may prevent automated approval or display of policy guidance and delay authorization.

• Add the procedure code first, then the diagnosis code when creating a code pair.
• If the code pair is not present, manual review or additional documentation may be required.

Preauthorization required — lack of authorization may trigger denial

Preauthorization is required for MA Specialty Testing: Cardiovascular; failure to obtain required preauthorization may lead to denial of the service.

• Obtain authorization before performing testing covered by this policy.
• Confirm authorization status through the payer's Quick Code Search tool.

Coverage subject to benefit contract terms

Services are subject to the terms and conditions of the applicable benefit contract; Medical Policies do not constitute authorization or guarantee payment.

• Verify member benefit coverage and contract terms prior to testing.
• Policies guide determination of scientific validity but do not replace benefit contract terms.