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ModifiedCommunity Health Plan WashingtonPolicy N/A

Concert Genetic Testing: Cardiovascular (Genetic testing for cardiovascular conditions)

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Defines medical necessity, coding, and usage guidance for genetic testing (multigene panels and targeted tests) for inherited and sporadic cardiovascular conditions for members of Community Health Plan Washington/Centene-affiliated health plans.

Policy Summary

PayerCommunity Health Plan Washington

PolicyConcert Genetic Testing: Cardiovascular (coverage criteria for genetic testing of inherited and sporadic cardiovascular conditions)

Policy CodePolicy N/A

Change TypeRevised coverage criteria and operational edits across multiple panel types (material changes included)

Effective DateN/A

Next Review DateN/A

Key ActionProvide phenotype-focused documentation and prior authorization demonstrating the listed diagnostic criteria when requesting genetic panel testing.

SourceLink

POLICY UPDATE CHANGES

Throughout the criteria, terminology and specific criteria were updated (e.g., replaced 'coverage criteria' with 'criteria'; multiple diagnostic wording changes across panels).

For Short QT syndrome, panel language was updated to refer to 'short QT syndrome (SQTS)' and to add other indications in section II.

For Brugada syndrome, multiple diagnostic phrasing edits were made including standardizing 'greater than or equal to 2 mm' for J-wave elevation and adding guidance to exclude phenocopies.

Policy title updated from Concert Genetic Testing: Cardiac Disorders to Concert Genetic Testing: Cardiovascular.

Added Brugada syndrome, CPVT, and Familial Hypercholesterolemia panels along with clinical guidance; updated numerous criteria and references to 2022 EHRA/HRS expert consensus and other guideline updates.

Post heart transplant gene expression panels expanded to include tissue-based panels and donor-derived cell-free DNA references updated (including code 0493U - Prospera).

Moved Known Familial Variant Analysis criteria for cardiac disorders into the general 'Genetic Testing: General Approach' policy; retired LV non-compaction cardiomyopathy panel criteria.

Familial Hypercholesterolemia criteria reformatted and updated to align with 2018 ACC guidelines; removed requirement that a definitive genetic diagnosis is needed prior to medication eligibility.

multiplepanel types

yesclinical criteria present

≤330 msSQTS QT cutoff

0493UDonor dd-cfDNA code

V1.2025/V2.2024document versions

Medical Necessity Criteria by Panel

Comprehensive Cardiomyopathy Panels (Medical Necessity)

Covered when ANY of the following are met:

Cardiomyopathy diagnosis or qualifying family history: A. The member/enrollee has a diagnosis of cardiomyopathy; OR B. The member/enrollee has a first-degree relative with sudden cardiac death (SCD) or sudden unexplained death (SUD) AND (1) the relative's autopsy revealed unspecified cardiomyopathy (e.g., cardiomegaly or cardiomyopathy) OR (2) the relative's autopsy revealed an anatomically normal heart AND (a) the autopsy did not reveal a cause of death.

Multigene panels targeted to the observed cardiomyopathy phenotype are recommended by professional guidelines.

Comprehensive Arrhythmia Panels (Medical Necessity)

Covered when ANY of the following are met:

Qualifying family history or unexplained arrest: A. Member meets one of: (1) first-degree relative with SCD or SUD before age 50; OR (2) first-degree relative with SCD at age ≥50 AND (a) deceased had family history of premature SCD OR (b) death is suspicious for genetic heart disease. OR B. Member has unexplained sudden cardiac arrest AND clinical tests were non-diagnostic for reversible, ischemic, or structural causes (e.g., ECG, stress tests, echocardiogram, pharmacologic provocation).

Policy Summary

PayerCommunity Health Plan Washington

PolicyConcert Genetic Testing: Cardiovascular (coverage criteria for genetic testing of inherited and sporadic cardiovascular conditions)

Policy CodePolicy N/A

Change TypeRevised coverage criteria and operational edits across multiple panel types (material changes included)

Effective DateN/A

Next Review DateN/A

Key ActionProvide phenotype-focused documentation and prior authorization demonstrating the listed diagnostic criteria when requesting genetic panel testing.

SourceLink

On This Page

Current evidence does not support comprehensive arrhythmia panels for other indications.

Comprehensive Arrhythmia and Cardiomyopathy (Sudden Cardiac or Unexplained Death) Panels

Covered when BOTH of the following criteria sets are met:

Combined panel criteria: A. Member meets clinical criteria for Comprehensive Cardiomyopathy Panels; AND B. Member meets clinical criteria for Comprehensive Arrhythmia Panels.

Comprehensive panels including genes for both cardiomyopathies and arrhythmias are considered medically necessary only when both sets of criteria are met.

Hypertrophic Cardiomyopathy Panels (Medical Necessity)

Covered when ALL of the following are met:

HCM genetic testing: Member has unexplained left ventricular hypertrophy (LVH) defined as myocardial wall thickness ≥ 15 mm in adults or z-score ≥ 2 in children based on echocardiogram or cardiac MRI.LV wall thickness ≥ 15 mm (adults); z-score ≥ 2 (children)

If a panel is performed, the appropriate panel code should be used.

Comprehensive cardiomyopathy + arrhythmia panels

Covered when BOTH of the following are met

Comprehensive combined panel coverage: A) Member meets clinical criteria for Comprehensive Cardiomyopathy Panels AND B) Member meets clinical criteria for Comprehensive Arrhythmia Panels

Comprehensive panels including genes for both cardiomyopathies and arrhythmias are considered medically necessary only when both sets of criteria are met.

Hypertrophic cardiomyopathy (HCM) panels

Covered when ALL of the following are met

HCM panel criteria: A) Unexplained LVH defined as myocardial wall thickness >=15 mm (adults) or z-score >=2 (children) by echo or cardiac MRIwall thickness >=15 mm; z-score >=2

If a panel is performed, use the appropriate panel code.

Dilated cardiomyopathy (DCM) panels

Covered when ALL of the following are met

DCM panel criteria: 1) Left ventricular enlargement or biventricular dilatation by echo or MRI; 2) Systolic dysfunction (e.g., EF <50%); 3) Non-genetic causes ruled out (e.g., prior MI, valvular/congenital disease, toxins, thyroid disease, inflammatory/infectious conditions, severe HTN, radiation)EF <50%

If a panel is performed, use the appropriate panel code.

Arrhythmogenic cardiomyopathy (ARVC) panels

Covered when EITHER major criteria OR two minor criteria are met

ARVC major criteria: Member has any one major task-force-like criterion (echo, MRI, RV angiography, biopsy, ECG epsilon/T-wave inversion, or family history/pathogenic variant) as listed in policysee individual imaging/ECG numeric thresholds in policy

If a panel is performed, use the appropriate panel code.

ARVC two minor criteria: Member has any two of the listed minor criteria (echocardiographic, MRI, biopsy, ECG, Holter, family history items) with specified numeric rangessee policy (e.g., PLAX/PSAX RVOT ranges, RVEF ranges)

Policy lists detailed numeric cutoffs for minor criteria.

Restrictive cardiomyopathy (RCM) panels

RCM panels: Current evidence does not support genetic testing for restrictive cardiomyopathy via multigene panel for any indications.

Not covered per policy.

Long QT syndrome (LQTS) panels

Covered when ANY of the following sets are met (A or B)

Asymptomatic LQTS criteria: Asymptomatic AND confirmed prolonged QTc (greater than 460 ms prepuberty; >480 ms adults) on resting ECG or provocative testing OR close relative with clinical LQTS whose genetic status is unknownQTc >460 ms (prepuberty); >480 ms (adults)

If a pathogenic variant in a relative is already known, refer to familial variant analysis criteria.

Symptomatic LQTS criteria: Symptomatic (syncope, cardiac arrest, aborted sudden death) AND either cardiologist-established strong clinical suspicion OR Schwartz score >=3.0; AND non-genetic causes of QT prolongation ruled outSchwartz score >=3.0

Non-genetic causes include QT-prolonging drugs, hypokalemia, structural heart disease, certain neurologic conditions.

Short QT syndrome (SQTS) panels

Covered when ANY of the following are met

QTc criterion: Member has a QTc of 330 ms or lessQTc <=330 ms

Electrocardiogram must be recorded without modifiers that shorten QT.

SQTS score criterion: Member has SQTS diagnostic score >=4 based on specified point system (ECG, Jpoint-Tpeak, clinical history, family history, genotype)SQTS score >=4

At least 1 ECG point required to obtain additional points; measurement rules specified in policy.

Asymptomatic with affected relative: Asymptomatic AND first-degree relative with clinical SQTS whose genetic status is unknown

If a familial pathogenic variant is known, follow familial variant analysis guidance.

Brugada syndrome (SCN5A) testing

Covered when ALL of the following are met

Brugada SCN5A criteria: A) Qualifying ECG pattern (Type 1, or Type 2/3 with conversion to Type 1 on challenge) in more than one right precordial lead; B) Rule out phenocopies (ischemia, electrolytes, drugs); C) Presence of clinical features such as recurrent syncope, VF, polymorphic VT, cardiac arrest, or family history of SCDECG pattern specifics in policy (J wave elevation ≥2 mm)

Genes other than SCN5A (including multigene panels) are not supported.

CPVT panels

Covered when ALL of the following are met

CPVT panel criteria: A) No known structural cardiac abnormalities; AND B) Any of: syncope during exercise/emotion; exercise/emotion-related palpitations/dizziness; sudden unexpected cardiac death triggered by exercise/emotion; family history of juvenile SCD triggered by exercise/emotion; exercise-induced bidirectional or polymorphic ventricular arrhythmias; ventricular fibrillation with acute stress

If a panel is performed, use the appropriate panel code.

Familial hypercholesterolemia (FH) panels

Covered when ALL of the following are met

FH panel general criteria: A) At least two or more elevated LDL-C measurements including assessment after intensive lifestyle modification; AND B) No apparent secondary cause of hypercholesterolemiaSee policy for age- and LDL-C-specific numeric thresholds (e.g., adult LDL-C ≥190 mg/dL)

Testing should at minimum include LDLR, APOB, PCSK9 sequencing and LDLR deletion/duplication analysis; consider expanded lipid panels.

Congenital heart malformation panels

Covered when ALL of the following are met

Congenital heart malformation panel criteria: A) Complex congenital heart malformation (e.g., hypoplastic left heart, transposition of the great vessels, tetralogy of Fallot); AND B) Clinical features do not fit a known genetic disorder for which targeted testing exists; AND C) Prenatal teratogen exposure considered and ruled out when possible

Not supported for simple CHD like VSD/ASD/PDA.

TAAD multigene panel

Covered when ALL of the following are met

TAAD panel criteria: A) History of aortic root enlargement, thoracic aneurysm, or type A/B aortic dissection; AND B) Does not meet diagnostic criteria for another connective tissue disorder; AND C) Family history of aortic dilation or dissection consistent with autosomal dominant inheritance

A multigene panel including known HTAD genes is recommended as the most cost-effective and clinically useful approach.

Hereditary hemorrhagic telangiectasia (HHT) panels

Covered when BOTH of the following are met

HHT panel criteria: A) Member has any clinical features of HHT (spontaneous recurrent epistaxis; mucocutaneous telangiectases; visceral AVM); AND B) Panel includes at minimum ACVRL1 and ENG genes

Genetic testing and counseling is essential for families of SCA/SUD victims when a genetic cause is suspected; autopsy tissue collection recommended for SUD investigation.

Hereditary Hemorrhagic Telangiectasia (HHT) multigene panel — Covered when ALL met

Covered when ALL of the following are met:

HHT panel coverage: Member has any of: spontaneous and recurrent epistaxis OR mucocutaneous telangiectases at characteristic sites OR visceral arteriovenous malformation (pulmonary, cerebral, spinal, gastrointestinal, or pancreatic)

From policy requirements for clinical features

Panel composition: Panel includes at minimum ACVRL1 and ENG genes

Minimum gene requirement for covered HHT panel

Comprehensive/Unfocused genetic testing for SCD/SCA — Not routinely covered

Policy stance:

Phenotype requirement: Hypothesis-free large unfocused gene panels, whole-exome or whole-genome sequencing in cases without a clinical phenotype are not recommended for routine patient care

May be considered only in context of scientific effort; discouraged for routine coverage

Long QT Syndrome (LQTS) panels — Covered when criteria met

Testing recommended when clinical probability is high or QTc thresholds met:

High-probability LQTS: Index patients with high probability of LQTS (e.g., Schwartz score ≥3.5) — molecular testing for definitive genes (KCNQ1, KCNH2, SCN5A, CALM1-3)Schwartz ≥3.5

Class I recommendation per consensus statements

Asymptomatic QT prolongation: Asymptomatic patients with QTc >480 ms (prepuberty) or >500 ms (adults) — targeted LQT1-3 testing is recommendedQTc >480 ms (children), >500 ms (adults)

Class I per consensus statements

Dilated Cardiomyopathy (DCM) panels — Coverage stance

Genetic testing considered useful and recommended in many DCM patients:

DCM testing consideration: Genetic testing is useful in all DCM patients and recommended in those with highest yield; should be considered even without family history or associated clinical features

Per expert consensus

DCM diagnostic criteria: DCM established when left ventricular enlargement and systolic dysfunction present (EF <50%)EF <50%

Diagnostic context

Short QT Syndrome — Covered when

Short QT syndrome (SQTS) testing is recommended when diagnostic criteria/scores indicate sufficient probability.

High-probability SQTS: SQTS diagnostic score greater than or equal to 4 OR meets Class I clinical diagnostic criteria (QTc <=330 ms as consensus cutoff) with supporting clinical/family history and ECG evidence.score >=4 or QTc <=330 ms

Electrocardiogram must be recorded without modifiers that shorten the QT; at least 1 point required from ECG section before other points.

Brugada Syndrome — Covered when

Brugada syndrome testing recommendation tied to clinical and ECG criteria.

Brugada syndrome diagnostic requirement: Clinical suspicion (recurrent syncope, VF, polymorphic VT, cardiac arrest, family history of sudden cardiac death) AND a diagnostic Type 1 ECG pattern (J wave elevation >=2 mm with coved ST) in right precordial leads V1-V3, with or without sodium-channel blocker challenge.J wave elevation >=2 mm

Exclude Brugada phenocopies (ischemia, electrolytes, drugs) prior to diagnosis/testing.

CPVT — Covered when

Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) testing is indicated with characteristic clinical features.

CPVT suspicion: Individuals with syncope during exercise/emotion, exercise- or emotion-induced palpitations with bidirectional or polymorphic VT, sudden unexpected cardiac death triggered by exercise/emotion, or family history of juvenile sudden cardiac death triggered by exercise/emotion.clinical features as listed

Diagnosis established with structurally normal heart, normal resting ECG, and exercise/emotion-induced VT.

Familial Hypercholesterolemia — Covered when

Familial Hypercholesterolemia (FH) testing is recommended for individuals meeting clinical LDL-C thresholds or strong suspicion.

FH testing indications: Children with persistent LDL-C ≥160 mg/dL (or ≥190 mg/dL) and adults with persistent LDL-C ≥190 mg/dL (or ≥250 mg/dL for higher suspicion) without secondary cause, especially with affected first-degree relative or premature CAD; also adults with personal/family history of premature CAD and elevated LDL-C.LDL-C thresholds as specified in policy

Testing should at minimum include LDLR, APOB, PCSK9 sequencing and LDLR deletion/duplication analysis; consider expanded lipid panels.

TAAD — Covered when

Heritable Thoracic Aortic Aneurysm and Dissection (HTAD/TAAD) testing recommendation.

TAAD testing indications: Patients with aortic root/ascending aortic aneurysms or dissection and risk factors for hereditary thoracic aortic disease (e.g., syndromic features, presentation before age 60, family history of TAD or peripheral/intracranial aneurysms, unexplained early sudden death in relatives).clinical risk factors present

A multigene panel comprising HTAD genes is recommended as the most cost-effective and clinically useful approach.

HHT — Covered when

Hereditary Hemorrhagic Telangiectasia (HHT) testing.

HHT testing indications: Refer patients for diagnostic genetic testing to identify causative mutation in families with clinically confirmed HHT; consider testing when Curaçao criteria are not met but clinical features are suggestive (epistaxis, multiple telangiectases, visceral AVMs, family history).clinical features or family mutation present

If ENG and ACVRL1 negative, consider SMAD4 testing; multigene HHT panels including ACVRL1, ENG, SMAD4 are reasonable.

General coverage logic

Coverage is provided when policy-specific clinical criteria (disease-specific diagnostic findings, family history, or guideline-based indications) are met.

Guideline-based index cases: Molecular genetic testing for definitive disease-associated genes should be offered to index patients with a high probability diagnosis based on clinical history, family history, and diagnostic testing (e.g., LQTS: KCNQ1, KCNH2, SCN5A, CALM1-3 per EHRA/HRS 2022).Schwartz Score 3.5 for high probability LQTS

Refer to disease-specific sections for precise gene/panel lists and threshold definitions.

Transplant monitoring: Post-heart transplant peripheral blood gene expression panels and donor-derived cell-free DNA tests may be covered for monitoring rejection risk with an adopted default frequency of once every 12 months for routine monitoring absent guideline-specified regimens.once every 12 months (default)

Tissue-based post-transplant gene expression panels were added; see policy reference table for covered tests.

Current evidence supports use of comprehensive cardiomyopathy panels only when the member meets the policy's specified clinical criteria. Examples of qualifying indications include a documented diagnosis of cardiomyopathy or a first-degree relative with sudden cardiac death/sudden unexplained death with autopsy findings consistent with cardiomyopathy or an anatomically normal heart with no identified cause of death. Current evidence does not support use of these comprehensive panels for indications outside those specified in the policy (i.e., panels performed without meeting the listed clinical or family-history criteria).

Comprehensive panels that combine genes associated with both cardiomyopathies and arrhythmias are covered only when the member meets the full clinical criteria for both the Comprehensive Cardiomyopathy Panels and the Comprehensive Arrhythmia Panels. Current evidence does not support use of combined cardiomyopathy/arrhythmia panels for indications that fail to meet both sets of criteria.

Hypothesis-free genetic testing — including large unfocused multigene panels, whole-exome sequencing (WES), or whole-genome sequencing (WGS) — for sudden cardiac death (SCD) or sudden cardiac arrest (SCA) cases without an identifiable clinical phenotype is not recommended for routine patient care. Such testing may only be considered in the context of a scientific effort and may be excluded from coverage when used in the absence of a clinical phenotype.

Genetic testing for Brugada syndrome should be performed only after a diagnostic evaluation has excluded reversible causes and phenocopies (for example myocardial ischemia, electrolyte disturbances, or drug intoxication). The policy limits diagnostic genetic testing to SCN5A variant analysis when clinical criteria are met (diagnostic Type 1 ECG pattern or Type 2/3 with conversion on challenge plus relevant clinical features); testing of other Brugada-associated genes or broad multigene panels is not supported for diagnostic purposes.

Criteria for left ventricular non-compaction cardiomyopathy panels have been retired from this policy due to the rarity of testing; as a result, those panels are no longer supported here. Additionally, criteria and operational guidance for known familial variant analysis for cardiac disorders have been relocated to the consolidated "Genetic Testing: General Approach to Genetic and Molecular Testing" policy.

This clinical policy is intended to guide determinations of medical necessity and coverage decisions but does not constitute a contract or guarantee of payment or clinical results. All coverage is subject to the member's benefit terms, conditions, exclusions, limitations, and applicable state or federal laws and Health Plan administrative policies.

Billing and Code Examples

Comprehensive Cardiomyopathy Panels - example CPT/ICD codesmixed

81439	Comprehensive cardiomyopathy panels (example billing code listed)
I42.0	Dilated cardiomyopathy (example ICD-10 listed)
I42.1	Obstructive hypertrophic cardiomyopathy (example ICD-10 listed)
Z13.71	Encounter for screening for genetic and chromosomal anomalies (example ICD-10 listed)
Z82.41	Family history of sudden cardiac death (example ICD-10 listed)

Comprehensive Arrhythmia Panels - example CPT/ICD codesmixed

81413	Comprehensive arrhythmia panel (example CPT)
81414	Comprehensive arrhythmia panel add-on or larger panel (example CPT)
0237U	Proprietary lab test code referenced for arrhythmia panels
I45.81	Long QT syndrome (example ICD-10)

Arrhythmia/Channelopathy panel codesmixed

81403	Panel CPT code referenced for LQTS/SQTS/CPVT panels
81406	Panel CPT code referenced for arrhythmia-related testing
81407	Panel CPT code referenced for arrhythmia-related testing
81479	Unlisted molecular pathology procedure (example use)
S3861	HCPCS/S code referenced for Brugada panels

Familial Hypercholesterolemia panel codesmixed

81401	Familial hypercholesterolemia panel CPT example
E78.01	Familial hypercholesterolemia (example ICD-10)

TAAD (thoracic aortic aneurysm/dissection) panel codesmixed

81405	TAAD multigene panel CPT example
81408	Panel CPT code referenced for TAAD testing
I71.00-I71.9	Aortic aneurysm ICD-10 range (example)
Q87.5	Congenital malformation syndromes predominantly associated with short stature (example listed with TAAD panels)

Panel coding note — general coding guidance for panelsmixed

No codes listed

Coding references and edits (policy updates reflected in code tables)mixed

No codes listed

Policy reference table additions — donor-derived cfDNA code addedHCPCS

0493U

Prospera (Natera) - donor-derived cell-free DNA

LV wall thickness for HCM — key thresholds

Adult thresholdLeft ventricular (LV) myocardial wall thickness ≥15 mm by echocardiogram or cardiac MRI

Pediatric thresholdLV myocardial wall thickness z-score ≥2 in children

Measurement basisThresholds based on maximal end-diastolic wall thickness on imaging (echo or cardiac MRI)

HCM wall thickness — adults >= 15 mm; children z-score >= 2

Primary adult diagnostic cutoffMaximum end-diastolic LV wall thickness ≥15 mm in adults

Pediatric diagnostic definitionLV wall thickness z-score ≥2 in children

Contextual noteIn family members or with positive genetic testing, lesser hypertrophy (13–14 mm) may be diagnostic per guideline context

DCM ejection fraction threshold

Systolic dysfunction thresholdLeft ventricular ejection fraction (LVEF) <50% by echocardiogram, cardiac MRI, or left ventricular angiogram

Required imagingDiagnosis based on LV enlargement or biventricular dilatation plus reduced EF documented by echo or MRI

Exclusion noteNon-genetic causes (e.g., prior MI, valvular disease, toxins, thyroid, inflammatory/infectious causes, severe HTN, radiation) should be ruled out

LQTS and SQTS QTc cutoffs

Prepubertal LQTS QTc cutoffQTc >460 ms in prepubertal individuals

Adult LQTS QTc cutoffQTc >480 ms in adults (asymptomatic Class I testing threshold)

SQTS diagnostic QTc cutoffShort QT Syndrome diagnostic QTc ≤330 ms

ARVC MRI RVEDV/BSA thresholds

ARVC major MRI RVEDV/BSA (male)>110 mL/m2 (Rao RVEDV/BSA) — major criterion

ARVC major MRI RVEDV/BSA (female)>100 mL/m2 (Rao RVEDV/BSA) — major criterion

Minor MRI RVEDV/BSA ranges100–110 mL/m2 (male) or 90–100 mL/m2 (female) — minor criterion ranges

Dilated cardiomyopathy systolic dysfunction EF <50%

DCM systolic dysfunction definitionEjection fraction (EF) <50% defines systolic dysfunction for dilated cardiomyopathy

Diagnostic componentsDCM diagnosis requires LV enlargement or biventricular dilatation plus systolic dysfunction on imaging

Measurement methodsEF measured by echocardiogram, cardiac MRI, or left ventricular angiogram

Schwartz score thresholds

Low probabilitySchwartz score ≤1 = low probability of LQTS

Intermediate probabilitySchwartz score 1.5–3.0 = intermediate probability of LQTS

High probabilitySchwartz score ≥3.5 = high probability of LQTS

Short QT Syndrome diagnostic QT cutoff

SQTS diagnostic QT cutoffQTc ≤330 ms — consensus diagnostic cutoff for Short QT Syndrome

SQTS score high-probabilitySQTS diagnostic score ≥4 = high probability

ECG recording requirementECG must be recorded without modifiers known to shorten the QT

LQTS QTc thresholds for asymptomatic patients (Class I testing thresholds)

Asymptomatic pediatric threshold for Class I LQTS testingQTc >480 ms in prepubertal patients qualifies for Class I testing consideration

Asymptomatic adult threshold for Class I LQTS testingQTc >500 ms in adults qualifies for Class I testing consideration

Use of Schwartz scoreIn symptomatic patients, Schwartz score ≥3.0 supports testing consideration

Clinical measurement thresholds summary (QTc, SQTS score, LDL-C)

QTc short cutoff (SQTS)QTc ≤330 ms = SQTS diagnostic cutoff

SQTS diagnostic scoreSQTS score ≥4 = high-probability SQTS

LDL-C flag for FH testingLDL-C ≥190 mg/dL flagged as a common adult threshold prompting consideration of familial hypercholesterolemia testing

HCM wall thickness note (end-diastolic maximum thresholds)

Measurement timingWall thickness thresholds refer to maximal end-diastolic (maximal end-diastolic) LV wall thickness on imaging

Adult primary cutoffMaximum end-diastolic wall thickness ≥15 mm in adults defines HCM

Context for borderline valuesWall thickness of 13–14 mm may be diagnostic in family members or with a positive genetic test per guideline context

Ordering, Documentation, and Prior Authorization

Billing Rule

Coding verification and commonly billed panel CPTs

Providers should reference current CPT coding guidance and the Concert Platform registered tests before submitting claims. Commonly billed panel CPT codes for cardiomyopathy/arrhythmia and related panels include (examples): 81439, 81413, 81414, 81403, 81406, 81407, 81479, and relevant temporary codes (e.g., 0237U, 0493U where applicable). ICD-10 diagnosis codes commonly billed in support of panel requests may include I42.x series, I45.81, I49.8, Z13.71, Z82.41, Z82.49, Z84.81, and Z84.89. These lists are illustrative; inclusion does not guarantee coverage and providers must verify coding prior to claim submission.

Verify test-to-CPT mapping on the Concert Platform prior to billing
Illustrative CPTs: 81439, 81413, 81414, 81403, 81406, 81407, 81479
Illustrative HCPCS/other: 0237U, 0493U (Prospera)
Common supporting ICD-10: I42.0-I42.9, I45.81, I49.8, Z13.71, Z82.41, Z82.49, Z84.81, Z84.89

Prior Authorization

Prior authorization: meet listed clinical criteria and coverage terms

Prior authorization is required for multigene panel testing when seeking coverage under this policy. Prior authorization requests must demonstrate that the member meets the specific clinical criteria listed for the target phenotype (e.g., HCM, DCM, LQTS, Brugada, CPVT, FH, TAAD). Authorization decisions are subject to member benefit terms, contract exclusions, and applicable state or federal rules.

Submit supporting clinical documentation that directly maps to the policy criteria for the requested panel
Prior authorization does not override plan contract exclusions or member benefit limits
Check state Medicaid and Medicare NCDs/LCDs where applicable prior to submission

Note

Phenotype-focused testing recommended; avoid unfocused large panels

Phenotype-focused testing is recommended. Order multigene panels targeted to the clinical phenotype observed (for example, HCM-focused panels for unexplained LVH or LQTS-focused panels for confirmed prolonged QTc) rather than large, unfocused ‘‘hypothesis-free’’ panels. Large unfocused panels, whole-exome sequencing (WES), or whole-genome sequencing (WGS) are not recommended for routine evaluation when the phenotype is unknown.

If phenotype is known, select a panel limited to genes with established gene–disease validity for that phenotype
Unfocused large panels or WES/WGS may be considered only in research or specialized centers with appropriate justification

Prior Authorization

Panel-level prior authorization guidance and gene-content expectations

Panel-level prior authorization requests should specify the panel name, test provider, CPT codes being billed, and the clinical indication with documentation. For certain conditions the policy specifies minimum gene content (e.g., FH panels must include LDLR, APOB, PCSK9 and consider LDLRAP1, LIPA, ABCG5/8, APOE in expanded panels).

Include the specific panel gene list or lab test report showing included genes when available
For FH panels, document that LDLR, APOB, and PCSK9 analyses are included (sequencing ± deletion/duplication where indicated)
When donor-derived cfDNA (e.g., 0493U Prospera) or post-transplant gene expression tests are requested, reference the specific code and evidence supporting use

Documentation Required

Prior authorization and coverage are subject to benefits, exclusions, and law

Coverage and prior authorization approvals are conditional on the member's benefit contract, plan exclusions, and applicable laws and regulations. This clinical policy is guidance to assist coverage decisions but does not guarantee payment. Providers must verify member benefits and applicable state/Medicare rules.

Authorization is not a guarantee of payment; claims remain subject to benefit terms and exclusions
For Medicaid members, state Medicaid provisions take precedence if they conflict with this policy
For Medicare members, review relevant NCDs/LCDs and CMS guidance prior to applying policy criteria

Prior Authorization

Comprehensive panels combining cardiomyopathy + arrhythmia: dual-criteria required

Comprehensive panels that combine cardiomyopathy and arrhythmia genes are covered only when the member independently meets the medical necessity criteria for both comprehensive cardiomyopathy panels and comprehensive arrhythmia panels. Do not order combined comprehensive panels when criteria are met for only one phenotype.

Combined cardiomyopathy+arrhythmia panel authorization requires documentation meeting both sets of criteria
If only one phenotype meets criteria, order the targeted panel for that phenotype

Denial Risk

Restrictive cardiomyopathy panels: not supported

Restrictive cardiomyopathy (RCM) multigene panel testing is not supported by current evidence and is considered not medically necessary for all indications.

Do not submit prior authorization for RCM multigene panels; documentation of RCM alone does not meet criteria for panel testing under this policy

Documentation Required

Brugada documentation and phenocopy exclusion required

Before testing for Brugada syndrome, exclude phenocopies and reversible causes (e.g., myocardial ischemia, electrolyte disturbances, and drug-induced ECG changes). Testing is limited to SCN5A variant analysis for diagnostic purposes; multigene testing for BrS beyond SCN5A is not supported.

Document ECG pattern qualifying for Brugada (type 1–3 criteria and conversion with challenge testing if applicable)
Document exclusion of ischemia, electrolyte abnormalities, and offending drugs prior to authorization

Note

Scope changes and coding alignment (relocations, retired criteria, updated codes)

Scope and criteria relocations/updates: Known Familial Variant Analysis criteria have been moved to the General Approach to Genetic and Molecular Testing policy; Left Ventricular Non-Compaction panel criteria retired. Policy coding tables updated to include donor-derived cfDNA (e.g., 0493U Prospera).

Refer to the General Approach policy for Known Familial Variant Analysis operational criteria
Do not rely on retired LV non-compaction panel criteria; follow current policy guidance

Documentation Required

Required clinical documentation and evidence to support testing

Clinical evidence and guideline-based diagnostic criteria are required to support testing requests. Examples: HCM requires unexplained LV wall thickness ≥15 mm in adults (z-score ≥2 in children); DCM requires LV enlargement and EF <50% with non-genetic causes excluded; LQTS requires QTc thresholds or Schwartz score criteria; SQTS requires diagnostic score ≥4 or ECG thresholds; FH requires persistent elevated LDL-C measurements after lifestyle modification and exclusion of secondary causes.

Include imaging reports (echo/MRI) with measurements and EF where applicable
Include serial ECGs, QTc measurements, Schwartz or SQTS diagnostic scores where applicable
Include serial LDL-C lab results (at least two measurements) and documentation of lifestyle modification and rule-out of secondary causes for FH panels

Documentation Required

Proband-first testing and cascade testing workflow

Genetic testing should follow a proband-first approach: test the most clearly affected/index case first. Cascade testing of at-risk relatives is appropriate only after a pathogenic or likely pathogenic variant is identified in the proband. Order testing in the index case before targeted family-member testing.

Document that the index (proband) was tested first or provide rationale if index testing is unavailable
For cascade testing, submit the family variant and relationship to proband with authorization request

Documentation Required

Required documentation for SCA/SUD genetic evaluation

For survivors of sudden cardiac arrest (SCA), victims of sudden unexplained death (SUD), and their relatives, multidisciplinary evaluation and comprehensive autopsy (with tissue storage suitable for genetic analysis) are central. Authorization should include documentation of multidisciplinary review, autopsy findings, and phenotype-directed testing rationale.

Provide autopsy report, ECGs, imaging, and multidisciplinary consultation notes when available
If phenotype is unknown, hypothesis-free large panels or WES/WGS are not routinely supported

Note

Policy is guidance; check state/Medicare rules and exercise clinical judgment

This policy is guidance to support coverage determinations and is not intended to dictate medical practice. Providers must exercise clinical judgment, follow state and Medicare rules where applicable, and confirm coding and benefit applicability.

Review applicable NCDs/LCDs and state Medicaid provisions prior to applying policy criteria
This policy does not replace provider clinical judgment

Note

Not specified / other scenarios: provide clinical rationale and contact medical review

Not all possible test scenarios are specified in this section. When a requested test or clinical scenario is not explicitly addressed, provide detailed clinical rationale, relevant guideline support, and confirm coding on the Concert Platform. Contact the plan's medical review team for complex or unusual cases.

When in doubt, include detailed phenotype data, prior testing results, and consult genetic experts as needed
Use the Concert Platform to verify registered tests and coding

Policy Scope and Purpose

This policy addresses genetic testing for inherited and sporadic cardiovascular conditions, including structural and electrical cardiac disorders, vascular diseases, and lipid disorders. Genetic testing for hereditary cardiomyopathies and arrhythmias is complex and should be performed and interpreted in the context of clinical findings and family history; pre-test and post-test genetic counseling and involvement of cardiac genetics experts are strongly advised to support appropriate test selection and result interpretation.

Key Terms and Thresholds

Genetic counseling — definition and guidance for pre/post-test counseling

DefinitionPre-test and post-test genetic counseling that facilitates informed decision-making, addresses possibility of secondary or incidental findings, and includes a plan for returning results

Provider guidanceTesting decisions and interpretation should be performed by or in consultation with a cardiac genetics expert

Counseling recommendationPre-test and post-test counseling is strongly advised prior to genetic testing

Comprehensive panel — definition for multigene cardiomyopathy/arrhythmia panels

DefinitionA comprehensive panel is a multigene panel targeted to cardiomyopathy or arrhythmia phenotypes (or combined) used for diagnosis when specific clinical or family-history criteria are met

Phenotype focusPanels should be targeted to the observed cardiomyopathy or arrhythmia phenotype per professional guidelines

Coverage limitationComprehensive panels including both cardiomyopathy and arrhythmia genes are covered only when criteria for both panel types are met

LVH definition — myocardial wall thickness >=15 mm in adults or z-score >=2 in children

LVH definition (adult)Myocardial wall thickness ≥15 mm in adults (by echocardiogram or cardiac MRI)

LVH definition (child)LV myocardial wall thickness z-score ≥2 in children

ContextDefined as unexplained left ventricular hypertrophy for HCM panel eligibility

Ejection fraction definition for DCM — EF <50% by echo/MRI/angiogram

Ejection fraction definitionEjection fraction less than 50% measured by echocardiogram, cardiac MRI, or left ventricular angiogram defines systolic dysfunction for DCM

Diagnostic requirementDCM diagnosis requires LV enlargement or biventricular dilatation plus systolic dysfunction

Measurement methodsEF estimation typically from 2D echocardiogram or cardiac MRI; can also use left ventricular angiogram

QTc thresholds for LQTS and SQTS — LQTS >460 ms prepuberty, >480 ms adults; SQTS QTc <=330 ms

LQTS QTc thresholdsQTc >460 ms in prepubertal individuals; QTc >480 ms in adults for prolonged QT consideration

Asymptomatic Class I testing thresholdsAsymptomatic patients: QTc >480 ms (prepuberty) or >500 ms (adults) for Class I testing per guideline statements

SQTS QTc thresholdShort QT Syndrome diagnostic QTc cutoff ≤330 ms

HHT multigene panel — definition and when considered medically necessary

HHT panel definitionMultigene panel analysis to establish or confirm HHT; panel must include at minimum ACVRL1 and ENG

Clinical indicationConsidered medically necessary when patient has spontaneous recurrent epistaxis, characteristic mucocutaneous telangiectases, or visceral AVMs

Cascade testing noteCascade genetic testing of at-risk family members is recommended for pathogenic/likely pathogenic variants

LQTS testing indication — molecular testing recommended for definitive genes in high-probability cases

Indication for LQTS testingMolecular testing recommended for index patients with high-probability LQTS (e.g., Schwartz score ≥3.5) for definitive genes (KCNQ1, KCNH2, SCN5A, CALM1-3)

Intermediate probability guidanceIn intermediate-probability cases (Schwartz 1.5–3.0), testing of established genes may be considered; testing of disputed genes is discouraged

Testing contextTesting recommended after thorough phenotypic evaluation (ECG, Holter, exercise) per consensus guidance

Close relatives — definition of first-, second-, and third-degree relatives

First-degree relativesParents, siblings, and children

Second-degree relativesGrandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings

Third-degree relativesGreat grandparents, great aunts/uncles, great grandchildren, and first cousins

Phenocopy — definition

DefinitionPhenocopy: a trait or disease that resembles the trait expressed by a certain genotype, but in an individual who is not a carrier of that genotype

Clinical relevancePhenocopies (e.g., ischemia, electrolyte disturbances, drug effects) should be excluded before genetic testing for Brugada or LQTS

Policy noteFailure to exclude phenocopies may lead to inappropriate testing or denial

Premature coronary artery disease (CAD) — age thresholds definition

Male premature CADMale subjects at or under 55 years of age

Female premature CADFemale subjects at or under 65 years of age

Use in FH criteriaPremature CAD is used as a family-history marker in FH testing indications

Schwartz Score — clinical scoring system used for LQTS probability

PurposeSchwartz Score is a clinical scoring system incorporating history, ECG, and exercise findings to estimate probability of Long QT Syndrome

Probability ranges≤1 low; 1.5–3 intermediate; ≥3.5 high (guides testing decisions)

Use-caseUsed to select patients for molecular screening and cascade testing

Donor-derived cell-free DNA (dd-cfDNA) — definition and reference to Prospera (0493U)

DefinitionDonor-derived cell-free DNA (dd-cfDNA) is a blood-based assay used to detect donor DNA as a marker for heart transplant injury/rejection

Example test/codePolicy references Prospera (Natera) with billing code 0493U

Monitoring frequency noteDefault routine monitoring coverage frequency adopted as once every 12 months absent specific guideline regimens

Policy Changes and Version Notes

2023-03-23coding_and_criteria_revision

Operational edits across multiple panel sections including clarified diagnostic language, replacement of 'coverage criteria' with 'criteria', and changes to age thresholds and test inclusion/exclusion

2024-04-24coverage_logic_and_panel_additions

General coverage logic updated and new panels added including Brugada, CPVT, Familial Hypercholesterolemia (FH), and TAAD with guideline references updated to 2022 EHRA/HRS consensus

2024-04-24scope_and_relocation_of_criteria

Known Familial Variant Analysis criteria for cardiac disorders moved to the consolidated 'Genetic Testing: General Approach' policy and Left Ventricular Non-Compaction panel criteria retired

2025-11-24administrative_title_changeLatest

Policy title updated from 'Concert Genetic Testing: Cardiac Disorders' to 'Concert Genetic Testing: Cardiovascular' with minor non-clinical rewording across the document reflected in V1.2025 and V2.2024 revisions