CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pharmacogenetic Multi-Gene Panels for Psychiatric Medication Management

Covers evidence-based coverage and exclusions for pharmacogenetic multi-gene testing (panels of 5+ genes) to guide antidepressant and antipsychotic therapy for Neighborhood Health Plan of Rhode Island members; indicates applicable lines of business and Medicare distinction.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPharmacogenetic Multi-Gene Panels for Psychiatric Medication Management

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateJan 1, 2024

Key ActionObtain prior authorization using Neighborhood's authorization request forms and include documentation of a face-to-face visit within 30 days or specialist/tumor board recommendation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5+panel minimum genes

<=15panel maximum genes

30dface-to-face timeframe

RIte Care+covered lines

EFPexcluded line

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Coverage Criteria for Pharmacogenetic Multi-Gene Panels

Requests for biomarker testing that are the subject of a clinical trial or experimental protocol are excluded from coverage. Such tests do not meet the policy requirement that services be non-experimental and supported by medical and scientific evidence.

The policy excludes use of pharmacogenetic multi-gene panels (5 or more genes) when used for indications other than guiding antidepressant and/or antipsychotic medication management. Panels intended for non-psychiatric uses are considered unproven and not medically necessary.

Specific commercial panels are listed as examples of tests considered unproven or not medically necessary for the excluded indications. Examples named in the policy include GeneSight Analgesic, GeneSight ADHD, Pain Medication DNA Insights, PharmacoDx, and SureGene Test pain drugs.

Pharmacogenetic multi-gene panels used for indications other than guiding antidepressant or antipsychotic therapy are not medically necessary due to insufficient evidence. The policy specifies that covered panels are those used for psychiatric medication guidance only and that other uses (e.g., ADHD, cardiovascular, anthracycline management, polypharmacy) are unproven.

The policy explicitly states that the PrismRA molecular signature test is not medically necessary for evaluating likelihood of inadequate response to anti-TNF therapies for rheumatoid arthritis because evidence of efficacy is insufficient.

Indications Covered

Guiding treatment with antidepressant and/or antipsychotic medications in individuals with major depressive disorder or generalized anxiety disorder who have trialed and failed at least one medication.

Requests for Evidence Based Services are covered ONLY when ALL of the following criteria are met:

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Coding and Test Limits

Covered CPT Codesmixed

affected codes

Covered Codes: see Authorization Quick Reference Guide (codes not listed in policy text)

Maximum genes in covered panel

Policy maximumPanels must include no more than 15 relevant genes (<= 15 relevant genes)

Applies toPharmacogenetic multi-gene panels used to guide antidepressant and/or antipsychotic therapy

Coverage conditionPanel gene count requirement is one of the required criteria for medical necessity

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Providers must use Neighborhood Health Plan of Rhode Island's prior authorization request forms available on the provider website and follow the listed submission process.

Access forms: Providers > Provider Resources > Forms > Click here for a list of prior authorization request forms (forms listed alphabetically).
Phone assistance: Providers can call 1-800-963-1001 for requests/inquiries during and outside business hours.

Documentation Required

Required Documentation

Documentation must include evidence of a face-to-face visit with the ordering physician within the last 30 days or confirmation that the test was ordered during such a visit (or recommended by a Tumor Board or consulting specialist when applicable).

Provide clinical documentation supporting medical necessity and that the service was ordered and furnished by qualified personnel.

Member Eligibility Requirements

No additional eligibility top-level distinctions were specified in the policy. Coverage for evidence-based services and pharmacogenetic multi-gene panels follows the general coverage gateway criteria: the service must be safe and effective, supported by evidence, within accepted medical practice, appropriate to the member's current clinical needs, not excluded by other policy, documented by a face-to-face visit within the prior 30 days (or tumor board/consulting specialist recommendation), and ordered and furnished by qualified personnel.

Not Covered — Exclusions and Non‑Covered Uses

Panels used for ADHD, cardiovascular indications, anthracycline management, polypharmacy, or other non-psychiatric indications are not covered. The policy lists specific commercial panels as examples of tests falling into this not-covered group, including the named panels above, and indicates these uses are unproven and not medically necessary.

Key Definitions

Pharmacogenetic Multi-Gene Panel

DefinitionA pharmacogenetic multi-gene panel is a test that covers five or more genes to detect genetic polymorphisms that may affect drug response

Coverage gene count rangeFor covered psychiatric indications, panels must include at least 5 genes and no more than 15 relevant genes

Clinical purposeIntended to identify genetic variants that can inform selection or dosing of medications (e.g., antidepressants, antipsychotics)

Background and Rationale

Genetic variations can alter target protein expression and thus change response to medications. Identifying clinically relevant genetic polymorphisms can help predict drug response and guide selection of treatment regimens, including when pharmacogenetic testing is used to inform antidepressant and antipsychotic medication management.