ModifiedEmblemHealthPolicy AHS-G2043

Celiac Disease Testing - Lab Benefit Program (LBM)

Defines EmblemHealth's coverage criteria and limitations for serologic, genetic, biopsy, point-of-care, and multiplex testing related to diagnosis and monitoring of celiac disease for members under the Lab Benefit Program.

Policy Summary

PayerEmblemHealth

PolicyCeliac Disease Testing - Lab Benefit Program (LBM)

Policy CodePolicy AHS-G2043

Change TypeMaterial changes: removed genetic-testing criterion and CPT codesadded/reorganized coverage criteriaLBM scope expanded

Effective DateMar 1, 2023

Next Review Date

Key ActionOrder IgA anti-TTG with total IgA for symptomatic or at-risk individuals and follow recommended monitoring intervals (first follow-up 3–6 months; every 6 months until normalization).

SourceLink

POLICY UPDATE CHANGES

Removed Coverage Criteria 7, which referred to genetic testing, as the focus of this policy is routine testing for the diagnosis of celiac disease.

Removed CPT codes 81376, 81377, 81382, 81383 from Applicable.

Lab Benefit Program (LBM) expanded to include EmblemHealth HMO/ PPO (Non-City) Commercial, Medicare and Medicaid plans effective 10/1/2024.

Addition of new Coverage Criterion 1 & 2 and Addition of Coverage Criteria 11; former Coverage Criterion 4 reorganized into sub-criteria now numbered as 6.

Updated for clarity; no changes to coding or coverage criteria (multiple editorial updates/transfers to new templates).

3–6 monthsfirst follow-up visit

every 6 mo until normmonitoring interval

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

POC anti-TTGnot covered

panels >2 analytesnot covered

HMO/PPO/Medicare/MedicaidLBM expanded

Coverage Criteria

Primary coverage criteria

Tests and circumstances that meet or do not meet coverage criteria.

For individuals diagnosed with celiac disease who are IgA-sufficient: IgA anti-tissue transglutaminase (IgA anti-TTG) testing meets coverage criteria at the following intervals: first follow-up 3–6 months after diagnosis; every 6 months until normalization of anti-TTG levels; every 12–24 months thereafter.

For individuals diagnosed with celiac disease who are IgA-deficient: IgG endomysial antibody (IgG EMA), IgG deamidated gliadin peptide (IgG DGP), or IgG TTG testing meets coverage criteria at the following intervals: first follow-up 3–6 months after diagnosis; every 6 months until normalization of IgG levels; every 12–24 months thereafter.

For individuals with signs or symptoms of celiac disease: serologic testing with IgA anti-TTG plus total IgA meets coverage criteria for diagnostic evaluation (see Note 1 for signs/symptoms).

For at-risk individuals when IgA anti-TTG is negative or weakly positive: IgA endomysial antibody (EMA IgA) testing meets coverage criteria.

For individuals with clinical suspicion who are IgA deficient: IgG EMA, IgG DGP, or IgG TTG testing meets coverage criteria.

Children & special situations

For children under age 2 with clinical suspicion of celiac disease: testing for IgA and IgG antibodies to deamidated gliadin peptides (DGP) meets coverage criteria.
For individuals over age 2, DGP IgA/IgG testing may be used as a substitute for anti-TTG testing and meets coverage criteria.

For confirmation of celiac disease in individuals at high risk: small intestinal (duodenal) biopsy with pathological examination meets coverage criteria regardless of serologic result.

The following DO NOT meet coverage criteria: rapid antigen point-of-care anti-TTG tests; panel/multiplex testing or multi-analyte testing for more than two analytes; testing asymptomatic, low-risk individuals; anti-reticulin antibody testing; stool or saliva testing for celiac disease; serologic testing using HLA-DQ-gluten tetramer/flow cytometry assays.

Coverage criteria informed by guidelines

Coverage stance is informed by guideline recommendations addressing when to test, use of serology, role of biopsy, HLA testing, and special populations.

Endoscopy/biopsy: Upper endoscopy (EGD) with multiple duodenal biopsies is recommended to confirm diagnosis in children and adults with suspected celiac disease; biopsies also assist with differential diagnosis and require multiple samples (e.g., 1–2 from bulb plus 4 from distal duodenum).

Serology first-line: TTG-IgA (IgA anti-TTG) is the preferred single first-line serologic test (including children ≥2 years); a high-level TTG-IgA (≥10× upper limit of normal) combined with positive EMA on a second sample may be diagnostic in select pediatric (and in some adult) scenarios.

IgA deficiency & young children: In IgA deficiency or children <2 years, use IgG-based assays (DGP-IgG or TTG-IgG) and measure total IgA concurrently; combine testing approaches per guideline recommendations.

HLA/genetic testing role:

Testing, biopsy, and follow-up criteria

Clinical testing and diagnostic/monitoring criteria referenced from guidelines and LBM statements in the document chunk.

Initial screening: measure total IgA and TGA-IgA as the first-line serologic testing; if total IgA is low or patient is IgA-deficient, perform IgG-based testing (DGP IgG, EMA IgG, or TTG IgG).

No-biopsy pediatric pathway: allowed in select children when TGA-IgA ≥10× ULN and confirmatory EMA-IgA is positive on a second sample; use shared decision-making with family.

Biopsy sampling standards: when performing EGD for suspected CD obtain at least 4 biopsies from the distal duodenum and at least 1 biopsy from the duodenal bulb during a gluten-containing diet; ensure optimal orientation and request re‑cutting or second pathology opinion if serology and histology are discordant.

Follow-up timing: first follow-up visit 3–6 months after diagnosis, then every 6 months until TGA normalization, then every 12–24 months thereafter.

Persistent antibody action: if IgA-TGA levels do not decrease after 6–12 months on a gluten-free diet, review dietary compliance and repeat testing using the same assay/manufacturer; routine rebiopsy is not recommended and should be reserved for selected cases with diagnostic uncertainty or persistent clinical concern.

Coverage and clinical criteria

Clinical screening and diagnostic recommendations summarized from USPSTF and professional societies as presented in the policy.

Serology as first-line: use IgA-tTG (tissue transglutaminase IgA) as the preferred single first-line serologic test and measure total IgA concurrently to assess for IgA deficiency.

Alternate testing: in IgA-deficient patients perform IgG-based testing (IgG-DGP or IgG-TTG); combined IgA/IgG tests are options per clinical judgment.

Confirmatory biopsy: positive serology is typically followed by intestinal biopsy for histologic confirmation in most adults; pediatric guidelines permit no-biopsy diagnosis in specific serologic/HLA circumstances.

Screening of asymptomatic persons: USPSTF concludes insufficient evidence to recommend screening asymptomatic, average-risk individuals; prioritize testing those at increased risk (first-degree relatives, autoimmune conditions, genetic syndromes).

EMA usage: EMA IgA is highly specific and should be used as a confirmatory test when diagnosis is made without duodenal biopsy; EMA IgG is used only in IgA-deficient patients.

Revisions affecting coverage and applicability

Summary of material coverage-related revisions present in these chunks.

Removed coverage criterion referencing genetic testing: Coverage Criterion 7 (genetic testing) was removed so the policy focuses on routine diagnostic testing for celiac disease.

Removed CPT codes: CPT codes 81376, 81377, 81382, and 81383 were removed from the Applicable list.

Added/renumbered criteria: New Coverage Criteria 1 & 2 and Coverage Criterion 11 were added; a prior Criterion 4 was reorganized into sub-criteria (effective updates noted 3/15/2024).

Scope expansion: Lab Benefit Program (LBM) expanded to include EmblemHealth HMO/PPO (Non-City) Commercial, Medicare, and Medicaid plans effective 10/1/2024.

Coding and Procedure Codes

procedure codesmixed

Applicable CPT/HCPCS procedure codes referenced in policy section header (specific codes not present in this excerpt).

Policy contextmixed

No codes listed

Serologic test types (informational)mixed

Descriptions of serologic assays: anti-tTG IgA/IgG, EMA IgA/IgG, anti-DGP IgG/IgA with method sensitivity/comments.

Referenced procedure codesCPT

82784	Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each
83516	Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method
86231	Endomysial antibody (EMA), each immunoglobulin (Ig) class
86255	Fluorescent noninfectious agent antibody; screen, each antibody
86256	Fluorescent noninfectious agent antibody; titer, each antibody
86258	Gliadin (deamidated) (DGP) antibody, each immunoglobulin (Ig) class
86364	Tissue transglutaminase, each immunoglobulin (Ig) class
88305	Level IV - Surgical pathology, gross and microscopic examination, colon biopsy

Removed from Applicable CPT codesCPTNot Covered

81376	HLA test code (removed from Applicable list)
81377	HLA test code (removed from Applicable list)
81382	HLA test code (removed from Applicable list)
81383	HLA test code (removed from Applicable list)

Diagnostic test performance considerations — tTG IgA vs DGP

Relative performanceTG2-IgA (tTG IgA) generally shows higher sensitivity and specificity than DGP in multiple studies; one pediatric study reported tTG sensitivity 94% vs DGP sensitivity 91% but much lower DGP specificity (26%).

Pediatric specificity concernsHigh false-positive rates for anti-DGP reported in infants and some pediatric series; studies concluded DGP does not add diagnostic value beyond tTG in IgA-competent children.

Use in IgA deficiency/young childrenDGP (especially IgG-DGP) may be used as an alternative in IgA-deficient patients or when total IgA is low, but overall performance is lower than tTG IgA in many cohorts.

TG2-IgA high-positive threshold

High-positive threshold

Provider Actions, Workflow, and Operational Guidance

Documentation Required

Monitoring — IgA-sufficient patients

For individuals diagnosed with celiac disease who are IgA sufficient, serologic monitoring with IgA anti-tissue transglutaminase (IgA-TTG) meets coverage criteria as follows: first follow-up 3–6 months after diagnosis; then every 6 months until anti-TTG normalizes; thereafter every 12–24 months. Use the same assay/manufacturer for follow-up measurements to ensure comparability.

First follow-up: 3–6 months after diagnosis
Every 6 months until normalization of IgA-TTG
Every 12–24 months thereafter
Use same assay/manufacturer for serial IgA-TTG testing

Documentation Required

Monitoring — IgA-deficient patients

For individuals diagnosed with celiac disease who are IgA deficient, IgG-based serologic tests (eg, IgG endomysial antibodies, IgG deamidated gliadin peptide, or IgG TTG) meet coverage criteria on the same monitoring schedule as IgA-sufficient patients: first follow-up 3–6 months after diagnosis; every 6 months until IgG levels normalize; then every 12–24 months thereafter.

Definitions, Background, and References

TTG / tTG / TGA-IgA — definition

DefinitionIgA antibodies directed against tissue transglutaminase (TG2); commonly measured as tTG IgA (TGA-IgA) and considered the primary first-line serologic test for celiac disease.

MethodsAssays include commercial ELISA, in‑house ELISA, RIA, and other methods; cut-offs are assay-specific (arbitrary units) and vary by manufacturer.

Clinical useRecommended as first-line screening in IgA-competent individuals; total IgA should be measured concurrently to detect IgA deficiency.

DGP — definition and clinical uses

DefinitionDeamidated gliadin peptide (DGP) antibodies target deamidated gliadin peptides; tests available as IgA or IgG isotypes.

Clinical roles

Policy Summary

PayerEmblemHealth

PolicyCeliac Disease Testing - Lab Benefit Program (LBM)

Policy CodePolicy AHS-G2043

Change TypeMaterial changes: removed genetic-testing criterion and CPT codesadded/reorganized coverage criteriaLBM scope expanded

Effective DateMar 1, 2023

Next Review Date

Key ActionOrder IgA anti-TTG with total IgA for symptomatic or at-risk individuals and follow recommended monitoring intervals (first follow-up 3–6 months; every 6 months until normalization).

SourceLink

On This Page

HLA-DQ2/DQ8 testing is not required for all diagnoses but may be helpful in selected situations (serology–histology discrepancy, patients already on a gluten-free diet to guide the need for a gluten challenge); a negative HLA essentially rules out CD while a positive result does not confirm it.

Screening recommendations: Case-finding (testing symptomatic persons and first-degree relatives) is recommended; mass community screening is discouraged and USPSTF finds insufficient evidence to screen asymptomatic, average-risk persons.

Testing before/after starting GFD: Avoid reduction or avoidance of gluten before diagnostic testing. If the patient is already on a gluten-free diet, reintroduction (for example ~3 slices of wheat bread daily for 1–3 months) is suggested before repeat TG2-IgA determination.

Novel tests & advanced methods

NGS-based HLA typing shows high accuracy versus older methods and may be useful in high-volume clinical labs.
Point-of-care DGP-based tests (e.g., Simtomax) have variable sensitivity and may perform less well in children; novel point-of-care tests are not endorsed as replacements for standard serology.

Monitoring & refractory disease: Periodic serologic testing is recommended for monitoring; nonresponsive or refractory disease warrants confirmation of prior diagnosis, exclusion of ongoing gluten exposure, consideration of repeat biopsy, and further specialized evaluation as indicated.

Test timing: perform serologic testing while the patient is on a gluten-containing diet for diagnostic accuracy; retest after gluten reintroduction if previously on a gluten-free diet.

Excluded modalities: urine, stool, or saliva measurements and intestinal-permeability tests are not recommended due to lower performance and do not meet coverage expectations.

High-risk conditions: recognize higher-risk populations for targeted testing (e.g., type 1 diabetes, autoimmune thyroid disease, autoimmune liver disease, Down syndrome, Turner syndrome, IgA deficiency, unexplained elevated aminotransferases).

>= 10 × ULN (upper limit of normal) for TG2-IgA (tTG IgA) is considered strongly predictive of active celiac disease.

Clinical implicationTG2-IgA ≥10× ULN combined with confirmatory EMA-IgA gives very high positive predictive value and may support non-biopsy pathways in select cases.

Assay considerationsOnly antibody tests with proper calibrator curve–based calculation and measurement range including 10× ULN should be used for applying this threshold.

TGA-IgA no-biopsy threshold

No-biopsy pediatric criterionTGA-IgA ≥10× ULN with a positive EMA-IgA on a second blood sample can be used to diagnose celiac disease without duodenal biopsy in select pediatric patients using shared decision-making.

Assay requirementsOnly antibody tests with proper calibrator curves and measurement ranges that include the 10× ULN value should be used for no-biopsy diagnosis.

Caveat in asymptomatic childrenIn asymptomatic children the PPV of high TGA-IgA ≥10× ULN may be lower, so decision to omit biopsy should consider pretest probability and involve family discussion.

Effective expansion date

Effective expansion dateLab Benefit Program (LBM) expanded to include EmblemHealth HMO/PPO (Non-City) Commercial, Medicare and Medicaid plans effective 10/1/2024.

Scope change noteExpansion recorded in Revision History as an operational scope change affecting plan lines under LBM.

Material change statusDocument lists this change as material in the Revision History entry effective 7/2024 (applies 10/1/2024).

First follow-up: 3–6 months after diagnosis

Every 6 months until normalization of IgG-based markers

Every 12–24 months thereafter

Note

Biopsy coverage

Small intestinal (duodenal) biopsy meets coverage criteria to confirm celiac disease in indicated patients and is appropriate regardless of serology when clinically warranted.

Biopsy of small intestine (duodenum) meets coverage criteria for confirmation

Documentation Required

HLA testing guidance

HLA genetic testing (HLA-DQ2/DQ8) has a limited role: it is not required for routine diagnosis but may be helpful in select situations (eg, serology-histology discrepancy, patients who began a gluten-free diet prior to evaluation). A negative HLA test effectively rules out celiac disease; a compatible haplotype may guide whether to offer a gluten challenge.

Not required for all cases; useful when serology and histology are discrepant
Effective negative predictive value — negative result rules out CD
Useful in patients already on a gluten-free diet to inform need for gluten challenge

Prior Authorization

Biopsy sampling and discordant result actions

Biopsy sampling should include at least four biopsies from the distal duodenum and at least one biopsy from the duodenal bulb while the patient is on a gluten-containing diet. For discordant results between TGA-IgA serology and histopathology, request re-cutting of biopsies and/or second opinion from an experienced pathologist.

Obtain ≥4 distal duodenal biopsies and ≥1 duodenal bulb biopsy on a gluten-containing diet
If serology and histology are discordant, request re-cutting of specimens and/or expert pathology second opinion

Note

No-biopsy pediatric diagnosis pathway

A no-biopsy diagnostic pathway may be considered in pediatric patients meeting strict criteria: TGA-IgA ≥10× upper limit of normal measured with an assay calibrated to report 10× ULN within its range, confirmation with a positive EMA-IgA on a second sample, normal total IgA for age, and shared decision-making with parent(s)/patient. Do not omit biopsy in IgA-deficient cases even if IgG-based serology is positive.

TGA-IgA ≥10× ULN (assay-capable of reporting 10× ULN)
Confirmatory positive EMA-IgA on a second blood sample
Normal total IgA for age
Shared decision-making with family/patient
Do not use no-biopsy pathway in IgA-deficient patients

Documentation Required

Follow-up testing and indications for rebiopsy

For persistent high or non-decreasing IgA-TTG after 6–12 months on a gluten-free diet, review dietary compliance and repeat IgA-TTG using the same assay from the same manufacturer. Routine rebiopsy is not recommended in children following a gluten-free diet; consider (re)biopsy only in selected cases when clinical grounds suggest doubt about the original diagnosis or concern for additional conditions.

If IgA-TTG remains high after 6–12 months on GFD: review diet and repeat same-assay IgA-TTG
Routine post-GFD rebiopsy not recommended in children
Consider (re)biopsy only for specific clinical indications (eg, uncertain original diagnosis, new concerning symptoms)

Documentation Required

Testing and confirmation workflow

Testing and diagnostic confirmation workflow aligns with guideline recommendations: initial serology for suspected celiac disease should include IgA-TTG plus total IgA. If IgA-TTG is negative or weakly positive in at-risk individuals, obtain IgA endomysial antibody testing. For IgA-deficient individuals, use IgG-based serology (IgG EMA, IgG DGP, or IgG TTG). For high-risk or confirmatory purposes, small-bowel biopsy is covered to establish diagnosis regardless of serology.

Initial testing: IgA-TTG + total IgA
If IgA-TTG negative/weak in at-risk persons: perform IgA EMA
If IgA deficient: use IgG-based tests (IgG EMA, IgG DGP, or IgG TTG)
Small-bowel biopsy covered to confirm diagnosis when indicated

Note

Revision notes — administrative

Administrative updates and revision history: policy content was transferred to the company-branded template and clarified without changes to coding or coverage criteria in recent updates. Specific revision notes include addition and reorganization of coverage criteria in 2023 and later template and scope clarifications; see full Revision History for details.

Policy content transferred to company-branded template; clarifications only, no coverage changes
2023 updates added and reorganized coverage criteria; see full Revision History for complete log

Used as alternative or adjunct testing in children <2 years and in individuals with IgA deficiency (IgG-DGP); may detect some tTG‑negative cases but overall performance is inferior to tTG IgA in many studies.

Performance caveatsHigh false-positive rates reported in infants and some pediatric cohorts; combined testing with tTG does not consistently improve diagnostic accuracy over tTG alone.

HLA‑DQ2 / HLA‑DQ8 — genetic markers

Genetic markersHLA‑DQ2 and HLA‑DQ8 are the principal genetic haplotypes associated with celiac disease susceptibility (most patients carry DQ2; remainder DQ8).

Negative predictive valueAbsence of HLA‑DQ2/DQ8 makes celiac disease very unlikely (strong negative predictive value), effectively ruling out CD in most contexts.

Positive result limitationPresence of HLA‑DQ2/DQ8 is common in the general population and is not diagnostic by itself (it does not confirm disease).

Signs and symptoms (Note 1)

Gastrointestinal featuresChronic or intermittent diarrhea, chronic constipation refractory to treatment, chronic abdominal pain, bloating, recurrent nausea or vomiting.

Extraintestinal featuresUnexplained weight loss, iron‑deficiency anemia, low bone density/osteoporosis, elevated liver enzymes, dermatitis herpetiformis, short stature/failure to thrive in children.

Associated conditionsType 1 diabetes, Down syndrome, Turner syndrome, Williams‑Beuren syndrome, and other autoimmune conditions prompt consideration of testing.

HLA‑DQ2/DQ8 testing — diagnostic value

Diagnostic utilityHLA‑DQ2/DQ8 testing detects CD‑compatible haplotypes and is useful to exclude CD when negative; it is not required for routine diagnosis when serology and histology are concordant.

Selected usesHelpful in serology–histology discrepancies, in patients already on a gluten‑free diet to guide need for gluten challenge, or to rule out CD in atypical presentations.

LimitationsA positive HLA result does not confirm CD and adds limited diagnostic value when other diagnostic criteria are already met.

TG2‑IgA ≥10× ULN — diagnostic implication

High TG2-IgA significanceTG2‑IgA ≥10× ULN is strongly predictive of active celiac disease and, when combined with EMA‑IgA positivity in a second sample, confers very high positive predictive value.

Use in diagnostic pathwaysThis high‑positive threshold underlies non‑biopsy diagnostic algorithms in pediatric guidelines and may inform biopsy decision‑making in adults.

Confirmatory testingEMA‑IgA is often used as the confirmatory serologic test when relying on high TG2‑IgA levels for diagnosis without biopsy.

Autoantibodies against tissue transglutaminase

DefinitionAutoantibodies against tissue transglutaminase (anti‑tTG) are immunoglobulins (IgA and IgG) directed against transglutaminase 2, used to detect celiac disease.

Assay typesMeasured by commercial ELISA, in‑house ELISA, RIA and other methods; assay sensitivity and cutoffs vary by method and manufacturer.

Clinical roletTG IgA is considered the primary first‑line serologic assay in IgA‑competent individuals; IgG assays used in IgA deficiency.

Anti‑endomysium antibodies (IgA, IgG)

DefinitionAnti‑endomysium antibodies (EMA) are detected by immunofluorescence and are highly specific (especially EMA‑IgA), used as a confirmatory test when diagnosis is made without biopsy.

Method and limitationsRequires immunofluorescence microscopy and experienced laboratory personnel; less sensitive than tTG IgA but more specific.

IgG isotype useEMA‑IgG is used only in patients with IgA deficiency as a confirmatory assay.

Anti‑DGP — definition and use

DefinitionAnti‑DGP are antibodies targeting deamidated gliadin peptides; available as IgA or IgG assays and serve as alternatives in certain scenarios.

Alternative useIgG‑DGP is an alternative in IgA‑deficient patients and may detect some tTG‑negative cases, but overall sensitivity/specificity are generally lower than tTG IgA.

Pediatric cautionHigh false‑positive rates reported in infants; DGP should be used cautiously in very young children and interpreted in clinical context.

Key serologic assays

Key assaysPrimary serologic assays include anti‑tTG (IgA/IgG), EMA (IgA/IgG), and DGP (IgA/IgG); tTG IgA is first‑line testing in IgA‑competent patients.

Assay performanceEMA is most specific but less sensitive than tTG IgA; DGP has lower sensitivity/specificity than tTG in many studies and may yield false positives in infants.

Regulatory contextSome assays are FDA‑cleared/approved; many labs also use validated laboratory‑developed tests (LDTs) under CLIA regulation.

LDTs and FDA‑cleared assays

LDTs explainedLaboratory‑developed tests (LDTs) are high‑complexity, CLIA‑regulated assays that are not FDA‑approved/cleared but may be used clinically after laboratory validation.

FDA clearanceSeveral commercial celiac assays have FDA clearance or approval; FDA‑cleared assays are listed elsewhere in the policy bibliography and FDA database.

Clinical implicationBoth FDA‑cleared assays and validated LDTs are used in practice; clinicians and laboratories should be aware of assay-specific performance and cutoffs.

Bibliography — selected references

Reference listPolicy cites multiple clinical studies and guideline documents (examples: ESPGHAN, ACG, AGA, USPSTF, WGO, NICE) supporting testing and diagnostic recommendations.

Selected key refsNotable references include: ACG 2023 guideline update; ESPGHAN 2020 pediatric guidelines; USPSTF screening summary and multiple diagnostic accuracy studies.

FDA sourcesFDA device approvals and summaries for specific celiac assays are cited (e.g., Quanta Lite, Aptiva) and included in the bibliography.

Revision History

Revision log overviewRevision History records edits including removal of genetic‑testing coverage criterion and removal of CPT codes 81376, 81377, 81382, 81383; policy formatting and scope changes are documented.

Material changesEffective 7/2024 entry notes LBM expansion (applied 10/1/2024) and March 2024 additions/reorganization of coverage criteria; later entries record code removals and template transfers.

Administrative updatesMultiple administrative and clarity updates noted (e.g., 11/2024, 10/2025) with some non‑material editorial changes recorded in the history.