CurrentUnitedHealthcarePolicy CS151ID.B

Carrier Testing Panels for Genetic Diseases (for Idaho Only)

This policy governs carrier testing panels for genetic diseases for UnitedHealthcare members in Idaho, including Idaho Medicaid Plus plans; clinical coverage criteria are governed by the Idaho Medicaid Provider Handbook, Laboratory Services, Chapter 4.8: Genetic Testing.

Policy Summary

PayerUnitedHealthcare

PolicyCarrier Testing Panels for Genetic Diseases (for Idaho Only)

Policy CodePolicy CS151ID.B

Change TypeRevised coverage guidanceremoved definitions

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionRefer to the Idaho Medicaid Provider Handbook, Laboratory Services, Chapter 4.8 for medical necessity clinical coverage criteria and related requirements.

SourceLink

POLICY UPDATE CHANGES

Replaced coverage guidelines with instruction to refer to the Medical Provider Handbook, Laboratory Services, Chapter 4.8: Genetic Testing for medical necessity clinical coverage criteria for genetic testing.

Removed definitions including Carrier Screening, First-Degree Relative, Panel, and Second-Degree Relative.

Removed Description of Services and Clinical Evidence sections.

IdahoGeographic applicability

Chapter 4.8Clinical criteria source

4+Sample codes listed

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Coverage and Medical Necessity

Determination of medical necessity

Coverage and medical necessity determination

Primary rule: Medical necessity clinical coverage criteria for genetic testing are determined by the Idaho Medicaid Provider Handbook, Laboratory Services, Chapter 4.8: Genetic Testing.

This policy defers to the Idaho Medicaid Provider Handbook for specific indications and criteria.

The inclusion of a procedure or diagnosis code in this policy is for reference only and does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage, reimbursement, and claim payment are determined by applicable federal, state, or contractual benefit requirements and other UnitedHealthcare policies and guidelines.

This policy does not itself list specific services as not medically necessary. Determinations about medical necessity, including not-medically-necessary conditions, must follow applicable federal, state, or contractual requirements and the clinical criteria referenced by this policy.

Covered indications

Primary rule: Medical necessity indications for genetic testing are not specified in this policy; refer to the Idaho Medicaid Provider Handbook, Laboratory Services, Chapter 4.8: Genetic Testing for covered indications.

Policy intentionally redirects reviewers and providers to the Idaho Medicaid Provider Handbook for clinical coverage criteria.

Procedure Codes and Panel Thresholds

Note

Code listing is informational

The following procedure and diagnosis codes are provided for reference only and may not be all inclusive. Inclusion of a code does not imply coverage, reimbursement, or guarantee of payment. Benefit coverage is determined by the member's contract, applicable laws, and other policy provisions.

CPT codes shown below are informational; verify coverage with member benefits and prior authorization rules.

Informational CPT/PLA codesmixed

0400U	Obstetrics (expanded carrier screening), 145 genes by next generation sequencing, fragment analysis and multiplex ligation dependent probe amplification, DNA, reported as carrier positive or negative.
81412	Genomic sequence analysis panel for Ashkenazi Jewish–associated disorders; panel must include sequencing of at least 9 genes (e.g., ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, SMPD1).
81443	Genomic sequence analysis panel for severe inherited conditions; panel must include sequencing of at least 15 genes (examples: ACADM, ARSA, ASPA, ATP7B, BCKDHA, BCKDHB, BLM, CFTR, DHCR7, FANCC, G6PC, GAA, GALT, GBA, GBE1, HBB, HEXA, IKBKAP, MCOLN1, PAH).
81479	Unlisted molecular pathology procedure.

Documentation Required

Code listing is informational — provider action

Provider action: Verify member benefits, medical necessity, and any prior authorization requirements before ordering or billing genetic testing. Document clinical indication and the specific genes requested; inclusion of a code in this policy does not alone authorize payment. Use the unlisted code 81479 only when no specific code describes the service and submit full documentation with the claim.

What Providers Must Do

Prior Authorization

Prior authorization guidance (informational policy)

This policy is informational and does not by itself establish prior authorization requirements; providers must follow any applicable federal, state, or contractual prior authorization rules and plan-specific processes.

Follow applicable federal, state, and contractual requirements and any plan-specific prior authorization processes.

Note

Follow governing benefit and plan rules

Follow applicable federal, state, and contractual benefit and plan rules when ordering or billing for these tests; this policy does not create new provider obligations beyond those requirements.

Documentation Required

Check applicable benefit terms

Check the federal, state, or contractual benefit plan terms for coverage determinations; in the event of a conflict, those federal, state, or contractual requirements govern.

Member Eligibility

No top-level eligibility criteria are specified in this policy. Refer to the applicable benefit plan, contract terms, and the Idaho Medicaid Provider Handbook, Laboratory Services, Chapter 4.8: Genetic Testing for any eligibility requirements that apply to genetic testing services.

No top-level eligibility criteria are specified in this policy. Providers and reviewers should consult plan documents, contracts, and state-specific rules (for Idaho, see the Idaho Medicaid Provider Handbook, Chapter 4.8) for any eligibility requirements.

Not Covered / Exclusions

This policy does not list explicit test-level exclusions. The codes presented are informational only and their presence does not imply coverage or non-coverage. Coverage decisions must be made in accordance with federal, state, or contractual benefit requirements and other applicable UnitedHealthcare policies.

Background and Scope

This policy addresses carrier testing panels for genetic diseases and directs users to the Idaho Medicaid Provider Handbook, Laboratory Services, Chapter 4.8: Genetic Testing for medical necessity clinical coverage criteria. Laboratories that perform genetic testing are regulated under the Clinical Laboratory Improvement Amendments (CLIA), and FDA approval alone is not a basis for coverage. When using this policy, check applicable federal, state, or contractual requirements; in the event of a conflict, those requirements govern. (See Policy History for the 08/01/2025 revision directing users to the Idaho Handbook.)

Definitions and Regulatory Notes

Removed definitions

Removed definitionsDefinitions previously included in the policy (Carrier Screening; First‑Degree Relative; Panel; Second‑Degree Relative) have been removed from this version.

Operational notePolicy history indicates the definitions were removed and prior version CS151ID.A was archived.

Reference guidanceRefer to the Idaho Medicaid Provider Handbook, Laboratory Services, Chapter 4.8 for applicable definitional or coverage details.

CLIA regulation

CLIA regulationLaboratories that perform genetic tests are regulated under the Clinical Laboratory Improvement Amendments (CLIA) Act of 1988.

Informational resourceAdditional CLIA and FDA regulatory information available at the FDA IVD regulatory assistance webpage (link provided in policy).