CurrentUnitedHealthcarePolicy CS048OH.E

Genetic Testing for Cardiac Disease

UnitedHealthcare medical policy for Ohio governing coverage and documentation requirements for genetic testing related to cardiac disease (e.g., familial hypercholesterolemia, hereditary cardiomyopathy, LQTS, Marfan), referencing InterQual criteria and Ohio Administrative Code for medical necessity determinations.

Policy Summary

PayerUnitedHealthcare

PolicyGenetic Testing for Cardiac Disease

Policy CodePolicy CS048OH.E

Change TypeDocumentation and references updated

Effective DateMar 1, 2026

Next Review Date

Key ActionProviders must ensure patient medical records contain relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures that fully support medical necessity and be able to make them available upon request.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying medical records documentation requirements to support medical necessity, including that documentation may be required and must be legible and available upon request.

Updated Clinical Evidence and References sections to reflect the most current information.

4Listed covered conditions (InterQual referenced)

13Specific CPT/PLA molecular codes referenced

1State-specific policy (Ohio)

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.

Coverage Summary

UnitedHealthcare medical policy for Genetic testing for cardiac disease in Ohio (Policy Number: CS048OH.E, Effective Date: March 1, 2026) governing coverage and documentation requirements for testing related to inherited cardiac conditions (for example, familial hypercholesterolemia, hereditary cardiomyopathy, long QT syndrome, and Marfan syndrome). The policy references InterQual® CP: Molecular Diagnostics as the primary clinical criteria source and notes applicability to Ohio-specific benefit determinations.

Key facts

Listed covered conditions (InterQual referenced)4 (Familial Hypercholesterolemia; Hereditary Cardiomyopathy; Long QT Syndrome; Marfan Syndrome)

Specific CPT/PLA molecular codes referenced13 (examples: 0237U, 0401U, 0439U, 0440U, 0466U, 81410, 81411, 81413, 81414, 81439, 81479, 81493, etc.)

State-specific policy (jurisdiction)Ohio — policy applies only to the state of Ohio and medical necessity evaluated per OAC 5160-1-01

Documentation requirement summaryMedical records must fully support medical necessity (history, exam, diagnostic test results), be legible, maintained in record, and available upon request

Medical-Necessity Criteria

Medically Necessary Coverage (referenced InterQual criteria)

Genetic testing for cardiac disease is proven and medically necessary in certain circumstances when InterQual CP: Molecular Diagnostics clinical criteria are met for the listed conditions:

Covered indications when InterQual criteria met

Familial Hypercholesterolemia (FH)
Genetic Testing for Hereditary Cardiomyopathy
Long QT Syndrome (LQTS)
Marfan Syndrome

Application / Jurisdictional Constraint

Policy applicability and medical necessity evaluation

ALL of the following

This medical policy only applies to the state of Ohio.
Any requests for services that are stated as unproven or services for which there is a coverage or quantity limit will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01.

Documentation Requirements

Documentation that must be available to support medical necessity

ALL of the following

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage.
The patient's medical record must contain documentation that fully supports the medical necessity for the requested services, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and made available upon request.

Provider Actions / Prior Authorization

Documentation Required

Maintain medical records supporting medical necessity

Providers must ensure the patient’s medical record contains documentation that fully supports the medical necessity for the requested genetic testing, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, and that this documentation is legible, maintained in the record, and made available upon request.

Prior Authorization

Medical necessity review using InterQual and OAC

Coverage decisions require that the requested genetic testing meet the InterQual CP: Molecular Diagnostics clinical criteria for the named conditions; services stated as unproven or with coverage or quantity limits will be evaluated for medical necessity per Ohio Administrative Code 5160-1-01.

Relevant Codes

Specific proprietary (PLA) and CPT/Genetic/molecular codes referencedmixed

0237U	Cardiac ion channelopathies genomic sequence analysis panel including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A; includes small sequence changes, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions.
0401U	Cardiology (coronary heart disease [CHD]), 9 genes (12 variants), targeted variant genotyping, blood/saliva/buccal, algorithm reported as a genetic risk score for a coronary event.
0439U	Cardiology (CHD), DNA, analysis of 5 SNPs and 3 DNA methylation markers, qPCR/digital PCR, whole blood, algorithm reported as a 4-tiered risk score for 3-year risk of symptomatic CHD.
0440U	Cardiology (CHD), DNA, analysis of 10 SNPs and 6 DNA methylation markers, qPCR/digital PCR, whole blood, algorithm reported as detected/not detected for CHD.
0466U	Cardiology (CAD), DNA, genome-wide association studies (564,856 SNPs, targeted variant genotyping), patient lifestyle and clinical data, buccal swab, algorithm reported as polygenic risk to acquired heart disease.
81410	Aortic dysfunction or dilation genomic sequence analysis panel; must include sequencing of at least 9 genes including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK.
81411	Aortic dysfunction or dilation duplication/deletion analysis panel; must include analyses for TGFBR1, TGFBR2, MYH11, and COL3A1.
81413	Cardiac ion channelopathies genomic sequence analysis panel; must include sequencing of at least 10 genes including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A.
81414	Cardiac ion channelopathies duplication/deletion gene analysis panel; must include analysis of at least 2 genes including KCNH2 and KCNQ1.
81439	Hereditary cardiomyopathy genomic sequence analysis panel; must include sequencing of at least 5 cardiomyopathy-related genes (e.g., DSG2, MYBPC3, MYH7, PKP2, TTN).

1–10 of 12

1/2

Background

This UnitedHealthcare policy applies only to genetic testing for cardiac disease in the state of Ohio. Coverage determinations reference InterQual® CP: Molecular Diagnostics for clinical coverage criteria across listed inherited cardiac disorders (Familial Hypercholesterolemia, Hereditary Cardiomyopathy, Long QT Syndrome, Marfan Syndrome). The policy states that FDA approvals are informational only and that laboratories performing genetic tests are regulated under the Clinical Laboratory Improvement Amendments (CLIA) Act of 1988.

Definitions

InterQual CP: Molecular DiagnosticsProprietary clinical criteria used by UnitedHealthcare to determine medical necessity for molecular diagnostic testing.

OAC 5160-1-01Ohio Administrative Code section governing Medicaid medical necessity: definitions and principles; used to evaluate services stated as unproven or with coverage/quantity limits.