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    v1.0.28
    OpenPayerPolicy UpdatesGenetic & Molecular Testingmoda_health_plan_inc Genetic Testing Coverage Upda…
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    Currentmoda_health_plan_incPolicy N/A

    Genetic Testing — Medical Necessity and Coverage Criteria

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    Defines medical necessity, coverage criteria, required documentation, and applicable CPT/HCPCS codes for genetic and molecular testing services for Moda Health members.

    Policy Summary
    Payermoda_health_plan_inc
    PolicyGenetic Testing — Medical Necessity and Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJul 1, 2026
    Last ReviewJun 24, 2026
    Next Review DateJun 24, 2026
    Key ActionObtain prior authorization with chart notes, family history, and documentation of pre-test genetic counseling when required.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    200+CPT/HCPCS codes listed
    RequiredPre-test counseling required
    ExcludedDirect-to-consumer tests
    multiplePanels with min gene counts
    Not coveredExome/genome sequencing
    AppendixCovered diagnosis groups

    Coverage Criteria

    inv-01: Pregnancy-related testing

    Covered when ANY one of the following are met:

    Pregnancy-related criteria: a. Pregnant woman or couples planning pregnancy with a personal or family history of a genetic disorder.

    Pre-test genetic counseling must be provided by a qualified and appropriately trained practitioner.

    Pregnancy-related criteria: b. Pregnant woman or couples planning pregnancy with ancestry associated with high risk for a genetic disorder that meets the specific criteria for the test (refer to Clinical Care Guidelines/Milliman Care Guidelines).

    Pre-test genetic counseling must be provided by a qualified and appropriately trained practitioner.

    Pregnancy-related criteria: c. Testing of both parents (e.g., chromosome analysis, karyotype) after previous unexplained stillbirth, two or more first‑trimester miscarriages, or a previous child with a congenital abnormality.Two or more first‑trimester miscarriages
    Policy Summary
    Payermoda_health_plan_inc
    PolicyGenetic Testing — Medical Necessity and Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJul 1, 2026
    Last ReviewJun 24, 2026
    Next Review DateJun 24, 2026
    Key ActionObtain prior authorization with chart notes, family history, and documentation of pre-test genetic counseling when required.
    SourceLink
    On This Page
    Coverage CriteriaCoding and BillingCovered IndicationsProvider Actions and DocumentationEligibility RequirementsNot CoveredBackgroundDefinitionsRevision History

    Pre-test genetic counseling must be provided by a qualified and appropriately trained practitioner.

    Pregnancy-related criteria: d. Carrier screening for Cystic Fibrosis (CF) and testing for Spinal Muscular Atrophy (SMA) as part of standard prenatal care.

    Pre-test genetic counseling must be provided by a qualified and appropriately trained practitioner.

    Pregnancy-related criteria: e. Determination of fetal sex is NOT covered.

    Moda Health does not provide coverage for fetal sex determination.

    inv-02: Pre/Post Symptomatic Testing

    When specific disorder criteria are unavailable, ALL of the following must be met:

    Pre/Post Symptomatic Testing: a. Patient has signs/symptoms of a genetic disease or is at risk of inheriting the disease due to family history or ancestry, AND the requested genetic test has been proven in evidence‑based literature to be diagnostic of the specific disease or condition being tested for.

    Genetic tests not proven for the requested diagnosis are considered experimental/investigational.

    Pre/Post Symptomatic Testing: b. Test results may confirm or rule out the diagnosis when standard evaluation is non‑diagnostic.

    Refer to Moda Health MHMNC or Milliman Care Guidelines for disorder‑specific criteria when available.

    Pre/Post Symptomatic Testing: c. Test results will directly impact the course of treatment.
    Pre/Post Symptomatic Testing: d. Requests for procedures or services in a quantity or grouped as a panel are investigational if evidence does not support performing them as a group/panel.
    Pre/Post Symptomatic Testing: e. Pre‑test genetic counseling must be provided by a qualified and appropriately trained practitioner.

    Documentation of counseling should be included with prior authorization when requested.

    inv-03: Tumor marker genetic assays

    Select tumor marker genetic assays considered medically necessary (refer to MCG and Moda criteria for details):

    Tumor marker assays considered medically necessary: EndoPredict (CPT 81522) for breast cancer risk stratification; Oncotype DX for Breast Cancer (CPT 81519) for breast cancer risk stratification; Mammaprint 70‑gene breast assay (CPT 81521); Breast Cancer Index (refer to MCG A‑0532 for breast gene expression assays).

    Refer to MCG A‑0532 and Moda Health criteria for condition‑specific use and member eligibility.

    Tumor marker assays considered medically necessary: DecisionDX‑UM (uveal melanoma) (CPT 81552) for risk stratification in members presenting with primary, localized uveal melanoma.
    Tumor marker assays considered medically necessary: Prostate Cancer Genomic Assay (CPT 81541) — refer to Moda Health Medical Necessity Criteria for Prostate Cancer Genomic Assay (HCS‑0225).
    Tumor marker assays considered medically necessary: Myriad Integrated BRACAnalysis with myRisk and Myriad Colaris with myRisk (CPT 81479 when applicable) — refer to MCG A‑0499 (hereditary breast/ovarian) and MCG A‑0533 (Lynch syndrome) for indications.

    inv-04: Experimental / Investigational Tests

    The following named tests/panels are considered experimental/investigational (this is not an exhaustive list):

    Experimental/Investigational list: BRCAplus; CancerNext; ColoNext; DecisionDX for Glioblastoma multiforme or Cutaneous Melanoma; Genecept Assay; GeneSight Assay; PGXL Broad Spectrum Panel; Millenium PGT; AmpliChip; STAR SureGene; Genomind Neuropsych Pharmacogenetic report; Epigenetic methylation assays (e.g., EpiSign, epiSEEK); Gene Trails; Guardant360; Macula Risk PGX; mtSEEK whole mitochondrial genome; OncoGeneDX; Oncotype DX Colon; OncoVue; OvaNext; OvaSure; PancNext; Pathfinder TG Topographic; and other listed panels/assays due to insufficient evidence of clinical utility.

    This list is not all‑inclusive; tests lacking supporting evidence when requested as panels/groups are investigational.

    Direct-to-consumer genetic testing (for example, 23andMe and Color) is not covered. Genetic testing must be ordered by an appropriate provider, performed by a CLIA-approved laboratory, and meet the policy's medical necessity criteria for the specific indication.

    Exome and genome sequencing (CPT codes 81415–81417 and 81425–81427) and several large or specialized panels — including nuclear-encoded mitochondrial gene panels requiring ≥100 genes and whole mitochondrial genome sequencing with heteroplasmy detection — are explicitly listed as NOT covered in the policy.

    Specific procedure codes identified in the policy's 'CPT codes NOT covered' lists are excluded from coverage. Examples include multiple single-gene pharmacogenomic CPTs (e.g., CYP and DPYD codes), a range of molecular pathology and expression assay codes, and sequencing panels referenced in the not-covered tables; see the CPT lists for full code-level detail.

    Genetic testing for certain conditions is considered NOT medically necessary. The policy explicitly lists examples including familial Alzheimer disease, amyotrophic lateral sclerosis, age-related macular degeneration, narcolepsy, scoliosis, and several psychiatric diagnoses (depression, mood disorders, bipolar disorder, anxiety disorders, ADHD, anorexia nervosa).

    Use of CPT codes listed in the document's 'CPT codes NOT covered' sections is considered not covered / not medically necessary and may be denied if billed. Providers should consult the policy's CPT lists when selecting billing codes.

    Determination of fetal sex is explicitly stated as not covered (noted in the policy updates dated 1/2020).

    Coding and Billing

    Applicable CPT/HCPCS CodesCPT
    81105Human Platelet Antigen 1 genotyping (HPA-1)
    81106Human Platelet Antigen 2 genotyping (HPA-2)
    81107Human Platelet Antigen 3 genotyping (HPA-3)
    81108Human Platelet Antigen 4 genotyping (HPA-4)
    81109Human Platelet Antigen 5 genotyping (HPA-5)
    81110Human Platelet Antigen 6 genotyping (HPA-6w)
    81111Human Platelet Antigen 9 genotyping (HPA-9w)
    81112Human Platelet Antigen 15 genotyping (HPA-15)
    81161DMD (dystrophin) deletion and duplication analysis
    81162BRCA1 and BRCA2 full sequence and duplication/deletion analysis
    1–10 of 63
    1/7
    Covered CPT Codes (when criteria met)CPTCovered
    81352TP53 targeted sequence analysis
    81353TP53 known familial variant
    81357U2AF1 common variants analysis
    81360ZRSR2 common variant(s) analysis
    81362HBB common variant(s)
    81363HBB common variant(s) (duplicate listing)
    81364HBB duplication/deletion variant(s)
    81401Molecular pathology procedure, Level 2
    81408Molecular pathology procedure, Level 9 / multigene panels (examples listed)
    81414Catecholaminergic polymorphic ventricular tachycardia panel (genomic sequence analysis)
    1–10 of 39
    1/4
    CPT codes NOT coveredCPTNot Covered
    81175ASXL1 full gene sequence
    81176ASXL1 targeted sequence analysis
    81225CYP2C19 common variants
    81226CYP2D6 common variants
    81227CYP2C9 common variants
    81230CYP3A4 common variants
    81231CYP3A5 common variants
    81232DPYD common variants
    81291MTHFR common variants
    81313PCA3/KLK3 ratio
    1–10 of 35
    1/4
    CPT codes NOT coveredCPTNot Covered
    CPT codes NOT coveredMultiple CPT codes are listed as not covered in the policy (specific codes appear elsewhere in the full document).
    Covered ICD-10 Diagnosis Codes (Appendix 1)ICD-10Covered
    D56.0-D56.9Thalassemia
    D57.00-D57.819Sickle cell disorders
    D58.0-D58.9Other hereditary hemolytic anemias
    D66Hereditary factor VIII deficiency
    D67Hereditary factor IX deficiency
    D68.0-D68.9Other coagulation defects
    D70.0-D71Neutropenia
    E75.00-E75.6Disorders of sphingolipid metabolism and other lipid storage disorders
    F70-F79Intellectual Disabilities (examples: Gaucher, Niemann-Pick referenced)
    G10-G14Systemic atrophies primarily affecting the CNS (e.g., Huntington's, SMA)
    1–10 of 15
    1/2
    Medicare Part B diagnosis guidancemixed
    Medicare Part B Covered Diagnosis CodesReferences to Medicare Part B covered diagnosis codes applicable to existing NCD/LCDs; jurisdictions and Noridian contractor noted.
    Recurrent pregnancy loss threshold
    ThresholdTwo or more first-trimester miscarriages (recurrent pregnancy loss) qualifies testing of both parents (eg, chromosome analysis/karyotype)
    ContextApplies to pregnant women or couples planning pregnancy after previous unexplained stillbirth, repeated (two or more) first trimester miscarriages, or previous child with abnormality
    Required counselingPre-test genetic counseling must be provided by a qualified and appropriately trained practitioner
    Panel minimum gene counts
    Hereditary breast cancer panels>=14 genes (example list includes ATM, BRCA1, BRCA2, BRIP1, CDH1, MLH1, MSH2, MSH6, NBN, PALB2, PTEN, RAD51C, STK11, TP53)
    Hearing loss panels>=60 genes (copy number analysis for STRC and DFNB1 deletions required)
    Aortic dysfunction panels>=9 genes (includes FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, MYLK)

    Covered Indications

    inv-37: Covered multigene panel examples

    Covered when the genomic panel includes the specified minimum gene content and the clinical indication matches the panel purpose:

    Panel coverage example - Hereditary breast cancer: Genomic sequence analysis panel for hereditary breast/ovarian cancer is covered when sequencing includes at least 14 genes (examples include ATM, BRCA1, BRCA2, BRIP1, CDH1, MLH1, MSH2, MSH6, NBN, PALB2, PTEN, RAD51C, STK11, TP53).>=14 genes

    Panel must meet indication criteria elsewhere in the policy; duplication/deletion analyses may be required for specified genes.

    Panel coverage example - Hearing loss: Genomic sequence analysis panel for hearing loss (nonsyndromic and syndromic causes) is covered when sequencing includes at least 60 genes (examples include GJB2, CDH23, MYO7A, OTOF, SLC26A4, USH2A, and others).>=60 genes

    Duplication/deletion (copy number) analysis for STRC and DFNB1 (GJB2/GJB6) deletions is required when duplication/deletion analysis panel is requested.

    Panel coverage example - Aortic dysfunction/dilation: Genomic sequence analysis panel for aortic dysfunction/dilation (e.g., Marfan, Loeys‑Dietz, Ehlers‑Danlos) is covered when sequencing includes at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK.>=9 genes

    Duplication/deletion analyses specified for certain genes as indicated in the policy.

    inv-38: Hereditary syndromes and condition-specific panels

    Coverage for hereditary syndrome/condition‑specific panels is contingent on panel gene‑content and a matching clinical indication:

    Hereditary breast cancer panels: Covered when the genomic sequence analysis panel for hereditary breast/ovarian cancer includes sequencing of at least 14 specified genes (see policy examples) and the member meets clinical indication criteria.>=14 genes

    Duplication/deletion analyses for BRCA1, BRCA2 and other specified genes may be required depending on the panel.

    Hearing loss panels: Covered when the genomic sequence analysis panel for hearing loss includes sequencing of at least 60 genes and when clinical presentation supports testing (e.g., nonsyndromic or syndromic hearing loss).>=60 genes

    Copy number analysis for STRC and DFNB1 deletions required for duplication/deletion panels.

    Hereditary colon cancer (Lynch/FAP) panels: Covered when genomic sequence analysis panels for hereditary colon cancer syndromes include at least 7 genes (APC, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2) or duplication/deletion panels include at least 8 genes (APC, MLH1, MSH2, MSH6, PMS2, EPCAM, CHEK2, MUTYH) and when clinical indication aligns with the panel purpose.

    inv-39: Diagnostic testing for listed hereditary conditions

    Diagnostic genetic testing is covered for the following hereditary conditions and clinical encounters when testing is indicated by clinical presentation or appropriate screening/family history:

    Hematologic and hemoglobin disorders: Thalassemia and sickle cell disorders (ICD‑10 ranges D56.0‑D56.9; D57.00‑D57.819) — diagnostic molecular testing as clinically indicated.

    Include appropriate diagnostic codes and supporting clinical documentation.

    Hereditary coagulation and hemolytic disorders: Hereditary coagulation defects (e.g., factor VIII/IX deficiency, D66, D67) and other hereditary hemolytic anemias (D58.0‑D58.9) — genetically indicated diagnostic testing is covered.
    Lipid storage and metabolic disorders: Disorders of sphingolipid metabolism and other lipid storage disorders (E75.00‑E75.6) — diagnostic genetic testing when clinically indicated.
    Neuromuscular and neurodegenerative disorders:

    Provider Actions and Documentation

    Prior Authorization

    Prior authorization documentation

    Include provider chart notes, relevant family history, and documentation of pre-test genetic counseling from a qualified and appropriately trained provider with prior authorization requests when available.

    • Provider chart notes
    • Family history
    • Documentation of pre-test genetic counseling
    Prior Authorization

    Prior authorization for panel CPT codes

    Obtain prior authorization when submitting applicable multigene panel CPT codes (examples shown in policy) if the panel meets the policy's criteria and gene-content requirements.

    • Examples of panel CPT codes referenced: 81414, 81415, 81422, 81435
    • Ensure panel meets indication and minimum gene-count thresholds in policy before submission
    Prior Authorization

    Check CMS/NCD/LCD requirements

    When Medicare NCDs or LCDs apply, follow those coverage requirements (which may include prior authorization); check the CMS Medicare Coverage Database and Noridian LCDs for applicable local determinations.

    • CMS Medicare Coverage Database: http://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx
    • Noridian LCDs as applicable to contractor jurisdictions
    Note

    No additional action specified

    No specific additional provider action specified in this section of the policy beyond the documented prior authorization and counseling requirements.

    Step Therapy

    No step therapy requirements

    This policy does not specify any step therapy requirements for genetic testing in the provided sections.

    Note

    No explicit provider action listed

    (No specific provider action content provided in source for this placeholder.)

    Documentation Required

    Information required with prior authorization

    Prior authorization requests should include provider chart notes, family history, and documentation of pre-test genetic counseling from a qualified and appropriately trained provider.

    • Provider chart notes
    • Family history
    • Documentation of pre-test genetic counseling
    Documentation Required

    Document panel minimum gene content

    Document that the requested multigene panel meets the policy's stated minimum gene-content requirements (for example: hereditary breast cancer panels must include sequencing of at least 14 genes; hearing loss panels must include at least 60 genes).

    • Hereditary breast cancer panels: sequencing of at least 14 genes
    • Hearing loss panels: sequencing of at least 60 genes
    • Other panels: follow the specific minimum gene counts listed in the policy
    Documentation Required

    CMS/LCD compliance and documentation

    When CMS NCDs/LCDs are relevant, document compliance with those determinations and reference the CMS Medicare Coverage Database and Noridian LCDs for required documentation and jurisdictional guidance.

    • Reference CMS Medicare Coverage Database for NCD/LCDs
    • Check Noridian LCDs for applicable contractor jurisdiction requirements
    Denial Risk

    Investigational or unsupported panels may be denied

    Requests for panels or grouped tests that the policy identifies as investigational or where evidence does not support panel/group testing, and direct-to-consumer tests, may be considered investigational and denied.

    • Direct-to-consumer genetic testing (e.g., 23andMe, Color) is not covered
    • Panels listed as experimental/investigational in the policy may be denied
    Billing Rule

    Not-covered CPT codes may be denied

    Billing CPT codes listed in the policy's 'CPT codes NOT covered' sections (examples include exome/genome codes 81415-81417, 81425-81427 and numerous listed single-gene/panel codes) may trigger non-coverage and denial.

    • Exome/genome codes listed as NOT covered: 81415–81417, 81425–81427
    • Other not-covered codes are listed in the policy's CPT codes NOT covered sections
    Denial Risk

    Denial risk for non-covered CPT codes

    Claims submitted with CPT codes explicitly listed as 'NOT covered' in the policy are at risk for denial; verify code coverage before billing.

    • Examples of NOT covered codes are provided in the policy's CPT codes NOT covered lists
    • Confirm coverage status prior to claim submission to avoid denial
    Documentation Required

    Pre-test genetic counseling requirement

    Pre-test genetic counseling must be provided by a qualified and appropriately trained practitioner for pregnancy-related testing and pre/post symptomatic testing; documentation of counseling should be included with prior authorization when available.

    • Required for pregnancy-related and pre/post symptomatic testing
    • Documentation of pre-test counseling should accompany prior authorization requests
    Note

    Ordering provider and counseling qualifications

    Tests must be ordered by an appropriate provider and pre-test genetic counseling must be provided by a qualified and appropriately trained practitioner; ensure the ordering provider and counselor meet these expectations when submitting requests.

    • Genetic testing must be ordered by an appropriate provider
    • Pre-test counseling must be from a qualified and appropriately trained practitioner

    Eligibility Requirements

    Eligibility for coverage frequently depends on the individual's personal or family history of a genetic disorder or ancestry associated with high risk. For pregnancy-related testing, coverage is allowed when any one of the policy criteria is met (for example, a personal/family history of a genetic disorder, high‑risk ancestry meeting test-specific criteria, testing after recurrent pregnancy loss of two or more first‑trimester miscarriages, or standard CF and SMA screening). Pre- and post-symptomatic testing requires that the patient have signs/symptoms or be at risk due to family history/ancestry and that the test is supported by evidence and will directly affect management.

    When specific disorder criteria exist in Moda Health Medical Health MHMNC or referenced Milliman/MCG Care Guidelines, those condition‑specific criteria must be followed. In the absence of disorder‑specific criteria, requests for testing must meet the policy's general pre/post‑symptomatic requirements (signs/symptoms or familial/ancestral risk, diagnostic utility in the literature, and a demonstrated impact on treatment).

    Not Covered

    Direct‑to‑consumer genetic tests (for example, 23andMe and Color) are not covered. In addition, tests and panels identified in the policy as experimental/investigational (see the policy lists such as BRCAplus, CancerNext, Guardant360, EpiSign/epiSEEK, GeneSight, and others) are not covered due to insufficient evidence of clinical utility.

    The policy lists numerous CPT codes and certain assays as not covered. These include multiple pharmacogenomic single‑gene CPTs (e.g., CYP and DPYD family codes), many gene expression/profiling and protein‑based algorithmic assays (CPTs in the 81500–81554 range), large multigene sequencing panels, and other specified procedures; consult the 'CPT codes NOT covered' sections for the complete enumerated list.

    The policy reiterates that fetal sex determination is explicitly not covered and records this as an update in the policy's annual review history (1/2020).

    Multiple CPT codes are identified across the document as not covered; billing for these codes is at risk for denial. Providers should reference the policy's 'CPT codes NOT covered' sections when coding to avoid submission of non‑covered services.

    Background

    Genetic testing encompasses analyses of DNA, chromosomes, or proteins to detect inherited changes that may affect disease risk, diagnosis, or guide treatment. Results can be complex and should be accompanied by appropriate genetic counseling; covered test types in this policy include carrier and prenatal testing (for example, CF and SMA screening), hereditary cancer panels, tumor marker assays for risk stratification and treatment decision‑making, single‑gene testing, cytogenomic microarray, and multigene sequencing panels subject to the policy's gene‑content and indication requirements.

    Definitions

    Genetic testing (definition)
    DefinitionGenetic testing: tests ordered to look for inherited traits or diseases by analyzing DNA, chromosomes, or proteins to detect specific changes that may increase disease risk or affect offspring
    ScopeIncludes tests that search DNA for specific changes, chromosome analyses, and protein-based assays reflecting gene function
    Counseling noteDecisions to undergo testing should be made in conjunction with appropriate genetic counseling due to complexity of results
    Genomic sequence analysis panel
    DefinitionGenomic sequence analysis panel: a multigene sequencing panel defined in the policy by a minimum number of genes (policy gives condition-specific minimums and named examples)
    ExamplesHereditary breast cancer panel >=14 genes; hereditary colon cancer panel >=7 genes; hearing loss panel >=60 genes; aortic dysfunction panel >=9 genes
    DocumentationPanel must include the specified minimum gene content and meet clinical indication requirements to be covered
    Molecular pathology procedure levels
    Use in codingLevels are referenced with molecular pathology CPT codes (eg, 81408 for Level 9/multigene panels)
    ImplicationLevel indicates extent of sequencing, mutation scanning, and duplication/deletion analysis required for the procedure
    Annual Review History (metadata)
    DefinitionAnnual Review History: chronological record of policy reviews and revisions (eg, entries from 02/2013 through multiple annual reviews and updates including code and criteria changes)
    Example entriesIncludes review dates and notes (02/2013 initial table, 09/2013 added E/I language, 06/2018 added Mammaprint alignment with CMS, multiple code updates through 2019)
    PurposeDocuments policy maintenance, code updates, and revisions over time

    Revision History

    02/2013annual_review

    Added annual review table with review date, revisions, and effective date (effective 2013-03-01).

    09/2013annual_review

    Review added item clarifying tests must be proven for diagnosis or considered experimental/investigational and that multiple genetic panels must be medically necessary to be covered (effective 2014-09-25).

    08/2014annual_review

    Annual review with no changes (effective 2014-08-30).

    02/2016annual_review

    Annual review added section I.2, added section 3 for 14 pharmacogenetics tests, section 4 for investigational genetic panels, and new 2016 codes (effective 2016-02-15).

    02/2017annual_review

    Annual review updated to new template and revised statement (effective 2017-02-02).

    10/2017annual_review

    Added new genetic testing codes (effective 2017-10-25).

    06/2018annual_review

    Annual review added Mammaprint to criteria to align with CMS (effective 2018-07-01).

    11/2018annual_review

    Added definition of GBM and CM (effective 2018-11-19).

    06/2019annual_review

    Annual review with no changes (effective 2019-07-01).

    11/2019update

    Updated codes on covered and non-covered lists and marked code 81551 as investigational (effective 2019-11-15).

    2026-06-24annual_reviewLatest

    Last review recorded (policy effective 2026-07-01) as documented in policy header; no clinical policy statement material changes noted in brief metadata.

    >=7 genes (sequence); >=8 genes (dup/del)

    Refer to code‑specific criteria (e.g., CPT 81435/81436) and clinical guidelines.

    Selected neuromuscular and neurodegenerative disorders (e.g., Huntington disease, spinal muscular atrophy; ICD‑10 ranges G10‑G14) — diagnostic genetic testing when clinically appropriate.
    Congenital malformations, screening, and family history indications: Certain congenital malformations (e.g., Q75.0‑Q75.9), screening encounters (Z13.0‑Z13.89), and family history of relevant disorders (Z82.0‑Z82.8) — testing covered when clinically indicated.