DraftBlue Cross Blue Shield - New MexicoPolicy N/A

Genetic Testing Medical Genetics Policy

Defines documentation and procedure-level listing for molecular and genetic testing services and related specimen/testing codes for Blue Cross Blue Shield - New Mexico. Affects providers ordering genetic tests and submitting authorization/documentation.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyGenetic Testing Medical Genetics Policy

Policy CodePolicy N/A

Change TypeNo material changes (informational/catalog update)

Effective DateN/A

Next Review DateN/A

Key ActionInclude suggested medical record documentation (history & physical, notes, family genetic history, genetic counseling evaluation) with test requests to avoid delays or possible denials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20document chunks extracted

81400,81405Molecular Pathology levels

~200+Genes/tests enumerated

81479Unlisted molecular code

Coverage Criteria and Gene/Test Catalog

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gene_test_entries: Multiple gene entries each paired with a test type such as 'full gene sequence', 'duplication/deletion analysis', 'targeted sequence analysis', or 'extended targeted sequence analysis' across chunks 18 and 36.

This block is a catalog-style listing: each line in the source pairs a gene (or condition) with a suggested test type; it does not itself define eligibility criteria.

Wide range of hereditary conditions and drug-response testing

Covered examples include a wide range of hereditary conditions and pharmacogenetic/drug-response testing; suggested test types are shown in the gene catalog.

examples: Examples listed in the source include single-gene disorders (e.g., cystic fibrosis/CFTR), expanded-allele disorders (e.g., HTT, FXN, various spinocerebellar ataxias), mitochondrial disorders (e.g., MT-encoded genes such as MT-ATP6, MT-ND5), and cancer-related translocations/variants (translocation analysis if performed).

These are illustrative examples drawn from the enumerated gene/test list rather than separate eligibility rules.

Inherited and somatic condition examples with suggested test types

Various inherited and some somatic conditions are associated with the listed genes; each gene line pairs a condition with a suggested test type.

condition_test_pairs: The source lists numerous specific gene–condition pairs (examples: DBT — full gene sequence; DCX — full gene sequence for X-linked lissencephaly; DYSF — full gene sequence for limb-girdle muscular dystrophy; LRRK2 — full gene sequence for Parkinson disease), and indicates suggested test types such as full gene sequence, duplication/deletion analysis, or targeted sequence analysis.

No explicit coverage eligibility criteria are provided with these gene/condition lines; they function as a reference catalog of recommended test methodologies.

Procedure Coding and CPT References

Molecular Pathology CPT LevelsCPT

81400

Molecular Pathology Level

Molecular Pathology CPT LevelsCPT

81405

Molecular Pathology Level 6

Molecular Pathology CPT code referencedCPT

81405

Molecular Pathology Level 6

Unlisted molecular pathology codeCPT

81479

Molecular Pathology, Unlisted

inv-09: Expanded allele testing — evaluation to detect abnormal expanded alleles (no numeric threshold listed).

Test purposeEvaluation to detect abnormal expanded alleles (expanded‑allele testing) for disorders such as myotonic dystrophy type 1/2 and other repeat‑expansion diseases.

Example genesDMPK, CNBP, CSTB (expanded‑allele targets explicitly listed).

Numeric thresholdNo numeric repeat‑size threshold specified in the policy entry (document provides descriptive test purpose only).

Associated test typesMay be performed as targeted expanded‑allele analysis/STR analysis as listed in test type catalog.

Provider Actions, Documentation & Authorization Notes

Prior Authorization

Prior Authorization Required for Molecular Pathology Levels

Prior authorization is required for molecular pathology testing billed at CPT 81400 and 81405 (molecular pathology levels) and for unlisted molecular pathology testing (CPT 81479). Ordering providers must obtain authorization before submitting claims to avoid delays or denials.

Affected CPT codes: 81400 (Molecular Pathology Level), 81405 (Molecular Pathology Level 6), 81479 (Molecular Pathology, Unlisted)
Authorization must be obtained prior to testing for the listed molecular pathology levels and unlisted molecular pathology procedures
Include the specific gene/test name and reason for testing when requesting authorization

Documentation Required

Documentation Required — Medical Record and Test Paperwork

Suggested medical record documentation must be included with the authorization request and retained in the medical record. Failure to provide required documentation may result in denial or delay of the request.

Current History & Physical
Relevant clinical notes supporting medical necessity
Detailed family genetic history when applicable
Genetic Counseling Evaluation (pre- and/or post-test counseling documentation recommended)
Practitioner name, signature, NPI number, and date on test requisition/sample paperwork

Denial Risk

Denial Risk — Documentation Omission

Omitting the suggested documentation or required practitioner identifiers may trigger a denial or delay. Ensure ordering provider information and signatures are present on test forms.

Missing documentation is a denial risk
Ensure practitioner name, signature, NPI, and date accompany specimens and requisition forms

Note

Provider Action — Genetic Counseling & Ordering Requirements

Genetic counseling evaluation is recommended and should be included in the medical record when available. Ordering provider requirements (e.g., who may order testing) must be confirmed per payer-specific prior authorization instructions.

Include genetic counseling notes (pre- and/or post-test) when available
Confirm payer-specific ordering provider requirements during the authorization process

Background and Policy Scope

This policy section provides recommended documentation and a detailed catalog of genes and associated suggested test types. Suggested documentation listed includes Current History & Physical, clinical notes, Family Genetic History, and a Genetic Counseling Evaluation. The gene/test catalog enumerates numerous individual genes and paired testing approaches such as full gene sequence, targeted sequence analysis, duplication/deletion analysis, cytogenomic microarray, and specialized assays for expanded-allele disorders.

Definitions and Test Descriptions

inv-19: Molecular Pathology Level — CPT-level classification used to categorize molecular/genetic testing complexity (examples shown: 81400, 81405).

DefinitionCPT 'Molecular Pathology Level' — a procedure‑level classification used to categorize molecular/genetic testing complexity (document shows examples such as 81400 and 81405).

Example codes81400 (Molecular Pathology Level); 81405 (Molecular Pathology Level 6).

Usage in policyListed as procedure/CPT‑level entries to identify molecular pathology testing services that may require authorization and to group tests by complexity.

Associated documentationCode listings appear alongside gene/test entries (used to categorize full gene sequence, targeted analysis, duplication/deletion analysis, etc.).

inv-20: Cytogenomic microarray — Cytogenomic constitutional targeted microarray of the X chromosome interrogating genomic regions for copy number and SNP variants.

DefinitionCytogenomic constitutional targeted microarray of the X chromosome interrogating genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities (SNP‑based CGH microarray).

ScopeTargets the X chromosome to detect copy‑number changes and SNP variants associated with constitutional chromosomal abnormalities.

Reporting constraintDo not report with CPT 88271 (policy explicitly states 'Do not report with (88271)').

Typical useUsed for detection of chromosomal abnormalities related to X‑linked conditions as part of cytogenomic analysis.