ModifiedColorado Rocky Mountain Health PlansPolicy CS165OH.E

Genetic Testing for Neurological Disorders (for Ohio Only)

Coverage and medical necessity rules for multi-gene targeted panels and comprehensive genetic testing for heritable neurological disorders for members in Ohio; affects ordering clinicians, geneticists, and laboratories.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyGenetic Testing for Neurological Disorders (for Ohio Only)

Policy CodePolicy CS165OH.E

Change TypeMaterial revisions — coverage criteria and code removals

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionOrder multi-gene targeted panels (≥5 genes) only when clinical criteria are met and testing is ordered by or in consultation with a specified specialist; update billing to avoid removed CPT codes.

SourceLink

POLICY UPDATE CHANGES

Title changed from 'Genetic Testing for Neuromuscular Disorders (for Ohio Only) Coverage Rationale' to a new title.

Revised coverage language: multi-gene Targeted Panel testing (five or more genes) for neurological disorders is proven and medically necessary when specified clinical and ordering criteria are met.

Replaced prior language with updated wording that comprehensive panels evaluating multiple clinically distinct neurological disorder categories are unproven and not medically necessary.

Added statement that benefit coverage is determined by federal, state, contractual requirements and applicable laws.

Added language that medical records documentation may be required to assess clinical criteria and that documentation must support medical necessity and be made available upon request.

Added definitions for Ataxia, Comprehensive Panel, Congenital Myopathy, Metabolic Myopathy, and Targeted Panel; removed several prior definitions (CGH, NMD, NGS, VUS).

Removed CPT codes 0417U, 81440, 81460, and 81465 from applicable codes (listed repeatedly in policy history).

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5+Min genes for targeted panel

0216U,0217U,81448,81479Example applicable codes

01/01/2026Document effective

Coverage Criteria for Genetic Testing — Neurological Disorders (Ohio)

Targeted multi-gene panels (Initial coverage)

Multi-gene Targeted Panel testing (five or more genes) for neurological disorders is proven and medically necessary when ALL of the following are met:

Clinical presentation: The individual to be tested displays signs or symptoms of a heritable neurological disorder and the results are expected to directly impact medical management of that disorder.

Ordering clinician: The test is ordered by or in consultation with a medical geneticist, developmental pediatrician, or adult or pediatric neuromuscular or neurogenetics specialist.

Intended purpose: The test is intended to establish a genetic cause for any one of the following: Congenital or Metabolic Myopathy; Ataxia; Peripheral neuropathy; Hereditary spastic paraplegia; or Muscular dystrophy.

List provided in policy.

Targeted Panel (Initial testing) - Covered with criteria

Multi-gene Targeted Panel testing (five or more genes) for neurological disorders is proven and medically necessary when ALL of the following are met:

Targeted Panel medical necessity criteria: 1) The individual to be tested displays signs or symptoms of a heritable neurological disorder and the results are expected to directly impact medical management; 2) The test is ordered by or in consultation with a medical geneticist, developmental pediatrician, or adult or pediatric neuromuscular or neurogenetics specialist; 3) The test is intended to establish a genetic cause for one of: Congenital or Metabolic Myopathy, Ataxia, Peripheral neuropathy, Hereditary spastic paraplegia, or Muscular dystrophy.

Extracted from policy revision summary.

Comprehensive Panel - Not medically necessary

Comprehensive Panel tests that evaluate multiple genes associated with multiple categories of clinically distinct neurological disorders are:

Comprehensive panels: Considered unproven and not medically necessary when intended to evaluate multiple clinically distinct neurological disorder categories.

Policy states these are unproven and not medically necessary.

Comprehensive Panel tests that are designed to evaluate genes across multiple, clinically distinct neurological disorder categories are considered unproven and not medically necessary. The policy states these broad multi-condition panels lack sufficient evidence of clinical utility because genotype–phenotype correlations typically support targeted testing that is aligned to the patient’s presenting features rather than expansive panels that include genes unrelated to the phenotype.

Note: the referenced Japanese IPN case series excluded participants with PMP22 copy-number variant (CNV) findings from that dataset; this documents a scope limitation in that study and does not itself establish payer coverage for or exclusion of PMP22 testing. Providers should be aware that certain datasets referenced in the evidence base did not include PMP22 CNV-positive cases when interpreting study applicability to panel composition.

Policy language clarifies that multi-gene testing should be targeted to the clinical presentation: Targeted Panels (panels focused on a specific neurological disorder category) are supported when clinically appropriate, while Comprehensive Panels that evaluate genes across multiple distinct neurological disorder categories are considered unproven and not medically necessary because they include genes unrelated to the individual’s phenotype and lack supportive clinical evidence.

Historical policy updates removed specific CPT codes from the applicable codes list. The policy history repeatedly documents that CPT codes 0417U, 81440, 81460, and 81465 have been removed and therefore are no longer covered under this policy section.

The policy history explicitly records removal of certain CPT codes: CPT codes 0417U, 81440, 81460, and 81465 have been deleted from the policy’s applicable codes list and should not be used for claims under this policy.

Multiple policy-history entries reiterate that CPT codes 0417U, 81440, 81460, and 81465 were removed from the applicable codes list; tests billed using these codes are therefore not applicable under this policy revision.

Policy history sections consistently repeat the deletion of CPT codes 0417U, 81440, 81460, and 81465, indicating these codes are no longer part of the policy’s applicable code set and should not be relied on for coverage or prior-authorization requests.

Documentation in the policy history confirms that CPT codes 0417U, 81440, 81460, and 81465 have been removed; claims submitted with these codes may be denied or require alternate coding.

The policy history reiterates removal of CPT codes 0417U, 81440, 81460, and 81465, and notes that prior authorization processes and billing documentation should not reference these codes for services governed by this policy.

Several policy history entries reiterate that CPT codes 0417U, 81440, 81460, and 81465 were removed from the policy’s applicable codes and therefore are excluded from coverage under this revision.

The repeated policy-history notes make clear that CPT codes 0417U, 81440, 81460, and 81465 have been deleted from the applicable codes list; providers must use current applicable codes when submitting claims.

Across multiple revision entries the document reiterates removal of CPT codes 0417U, 81440, 81460, and 81465, reinforcing that these codes are not covered under this policy section and should be removed from billing and authorization workflows.

The policy history repeatedly documents deletion of CPT codes 0417U, 81440, 81460, and 81465; tests billed with these codes are no longer applicable to coverage under this policy.

Policy revision entries at the end of the history again list CPT codes 0417U, 81440, 81460, and 81465 as removed from the policy, indicating they are effectively excluded from coverage and should not be used for claims under this policy.

Comprehensive panels that include genes unrelated to the individual’s phenotype or that span multiple clinically distinct neurological disorder categories lack supporting clinical evidence of benefit and are therefore considered not medically necessary under this policy.

The policy explicitly states that Comprehensive Panel tests which evaluate genes across multiple clinically distinct neurological disorder categories are not medically necessary because available evidence does not demonstrate clinical utility for such broad, multi-condition testing in the evaluated populations.

Applicable Codes and Coding Notes

Applicable Codesmixed

0216U	Neurology (inherited ataxias), genomic DNA sequence analysis of 12 common genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants.
0217U	Neurology (inherited ataxias), genomic DNA sequence analysis of 51 genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants.
81448	Hereditary peripheral neuropathies (e.g., Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy-related genes (e.g., BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1).
81479	Unlisted molecular pathology procedure

Applicable Codes - RemovedCPTNot Covered

0417U	Removed CPT code from applicable codes
81440	Removed CPT code from applicable codes
81460	Removed CPT code from applicable codes
81465	Removed CPT code from applicable codes