CurrentCommunity Health Plan WashingtonPolicy N/A

Concert Genetic Testing: Orthopedics

Defines medical necessity criteria for genetic testing related to osteogenesis imperfecta (COL1A1/COL1A2) and multigene panel analysis for skeletal dysplasias and other rare bone disorders, including a list of covered disorders and required clinical features. Provides coding examples and references.

Policy Summary

PayerCommunity Health Plan Washington

PolicyConcert Genetic Testing: Orthopedics

Policy CodePolicy N/A

Change TypeRevised (name, coding, and content updates)

Effective DateN/A

Next Review DateN/A

Key ActionProviders must document the specific clinical features that meet medical necessity and obtain prior authorization as required, submitting supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

Policy name changed from 'Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders' to 'Concert Genetic Testing: Orthopedics'.

Added CPT codes 81401-81407 to Policy Reference Table and updated example tests.

Multigene Panel Analysis criteria clarified to specify 'post-natal' in one revision.

1OI criteria present

1Multigene panel category

20+Listed disorders referenced

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Coverage Summary

Defines medical necessity criteria for genetic testing related to osteogenesis imperfecta (COL1A1/COL1A2) and multigene panel analysis for skeletal dysplasias and other rare bone disorders, including a list of covered disorders and required clinical features. The tests and codes listed are examples and their inclusion does not guarantee coverage. Status: CURRENT. Last review: 2024-11-25.

Key thresholds and quick facts

Prenatal long bone shortening> 3 standard deviations below the mean

Postnatal short statureheight or length less than 3rd percentile

Prenatal head circumference> 75th percentile

Primary condition (detailed criteria) count1

Panel testing category count1

Listed disorders referenced20+

Osteogenesis Imperfecta (OI) — Medical Necessity

Osteogenesis Imperfecta - Not medically necessary

Current evidence does not support testing for the following:

COL1A1 and COL1A2 variant analysis or multigene panel analysis that includes COL1A1 and COL1A2 to establish or confirm a diagnosis of OI for all other indications not listed as medically necessary

Multigene Panel Analysis for Skeletal Dysplasia / Rare Bone Disorders — Medical Necessity

Multigene Panel Analysis - Not medically necessary

Current evidence does not support testing for the following:

Multigene panel analysis to confirm or establish a diagnosis of a skeletal dysplasia or a rare bone disorder for all other indications not listed as medically necessary

Other Covered Skeletal Dysplasias and Rare Bone Disorders

Coding (examples referenced)

Common billing CPT codes (examples referenced)CPTCovered

81400	Molecular pathology procedure level — example multigene panel reference
81401	Molecular pathology procedure level — example multigene panel reference
81402	Molecular pathology procedure level — example multigene panel reference
81403	Molecular pathology procedure level — example multigene panel reference
81404	Molecular pathology procedure level — example multigene panel reference
81405	Molecular pathology procedure level — example multigene panel reference
81406	Targeted gene sequence panel molecular pathology (example: COL1A1/COL1A2 panels)
81407	Molecular pathology procedure level — example multigene panel reference
81408	Molecular pathology procedure level — example multigene panel reference
81479	Unlisted molecular pathology procedure (used as example in policy)

ICD-10 / diagnosis codes referencedICD-10Covered

Q78.0	Osteogenesis imperfecta
Z82.79	Family history of other specified conditions (example family history of OI referenced)
M85	Other deforming dorsopathies / skeletal code family referenced in table
Q77	Other congenital musculoskeletal deformities (used in reference list)
Q78	Other congenital malformations of skeleton (used in reference list)

CPT and other billing codes listed in this policy are provided as examples for informational purposes; inclusion does not guarantee coverage. Providers should reference the most up-to-date CPT coding guidance and consult the Concert Platform for registered tests when preparing claims or prior authorization requests.

Provider Actions & Documentation Requirements

Documentation Required

Clinical features documentation

Providers must document the clinical features that satisfy the medical necessity criteria for genetic testing for skeletal dysplasia or other rare bone disorders. Documentation should clearly describe the signs, findings, or family history that meet policy criteria and support the requested test.

Fractures with minimal or no trauma (in the absence of non-accidental trauma or other known bone disorders)
Short stature (height or length < 3rd percentile)
Relevant prenatal ultrasound findings (e.g., limb shortening >3 standard deviations, bone irregularities, small chest circumference, abnormal ribs)

Prior Authorization

Prior authorization

Testing requests will be assessed against the policy medical necessity criteria. Prior authorization should be obtained when required by the member's plan prior to testing.

Background, Evidence, and Definitions

This policy addresses the use of genetic tests for rare skeletal dysplasias and other bone disorders and strongly advises pretest and post-test genetic counseling. Example laboratory tests (e.g., COL1A1/COL1A2 panels for OI and various commercial skeletal dysplasia multigene panels) and coding guidance (CPT/ICD-10 examples) are illustrative and not comprehensive; their inclusion does not represent a guarantee of coverage.

Evidence

Definitions / Notes

Revision History

11/25revisedLatest

Material change: Policy name changed from 'Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders' to 'Concert Genetic Testing: Orthopedics'; policy reference table, rationale, background, and references updated; 'Investigational' statements changed to 'current evidence does not support.'

04/24revised

Semi-annual review: Updated title versioning, consolidated Clinical Considerations into Overview, minor rewording for clarity, and updated coding, reference-table, background and references.

10/23

Administrative Details

Document metadata

PayerCommunity Health Plan Washington

Policy titleV2.2025 Concert Genetic Testing: Orthopedics

Policy numberN/A

Effective date

Last review date2024-11-25

StatusCURRENT