ModifiedUnitedHealthcarePolicy CS048ID.D

Genetic Testing for Cardiac Disease (for Idaho Only)

State-specific medical policy for genetic testing related to inherited cardiac arrhythmias, cardiomyopathies, thoracic aortic disease, and coronary artery disease risk — applies to Idaho (including Idaho Medicaid Plus).

Policy Summary

PayerUnitedHealthcare

PolicyGenetic Testing for Cardiac Disease (for Idaho Only)

Policy CodePolicy CS048ID.D

Change TypeClarificationRelated link added

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionVerify guideline-based diagnostic criteria and document phenotype (e.g., Schwartz Score, ECG, family history) when requesting genetic testing; confirm benefit/prior authorization per plan.

SourceLink

POLICY UPDATE CHANGES

Revised policy language to clarify that all other genetic testing for cardiomyopathies, arrhythmias, or aortic vascular disease is unproven and not medically necessary, with an explicit exception for chromosome microarray analysis for isolated severe congenital heart disease.

Added referenced link to the Chromosome Microarray Testing (Non-Oncology Conditions) related policy and updated Description of Services, Clinical Evidence, FDA, and References sections; previous policy version CS048ID.C archived.

IdahoState-specific

2026-05-01Policy revision date

Schwartz ≥3.5LQTS high-probability threshold

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.

50-75%CPVT 3-gene sensitivity

KCNQ1,KCNH2,SCN5AMajor LQTS genes

Coverage Criteria for Genetic Testing in Cardiac Disease

inv-01: Inherited Arrhythmias - Initial testing

Covered when ANY of the following inherited arrhythmia diagnoses are confirmed or suspected

Inherited arrhythmias - covered indications

LQTS subcriteria: Prolonged QTc (> 460 ms) on exercise/ambulatory ECG/Holter/pharmacologic provocation; or T wave abnormalities on ECG suggestive of LQTS (Torsade de pointes, T wave alternans, or notched T wave in 3 leads); or Profound congenital bilateral sensorineural hearing loss and prolonged QTc; or Schwartz Score ≥ 1.5 points

inv-02: Inherited Cardiomyopathies - Initial testing

Covered when ANY of the following hereditary cardiomyopathy diagnoses are confirmed or suspected

Inherited cardiomyopathies - covered indications: Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C); or Dilated cardiomyopathy (DCM) without identifiable cause when one of: cardiac conduction disease (1st-3rd degree block) OR sudden cardiac death in a first- or second-degree relative at age ≤45; or Hypertrophic cardiomyopathy (HCM) without identifiable cause; or Left ventricular noncompaction cardiomyopathy (LVNC)

inv-03: Inherited Thoracic Aortic Disease

Covered when confirmed or suspected thoracic aortic disease

Inherited thoracic aortic disease: Multi-gene panel testing is proven and medically necessary in individuals with confirmed or suspected thoracic aortic disease.

inv-04: Not Medically Necessary / Unproven

Not covered / Unproven testing statements

Not medically necessary - other genetic testing: All other genetic testing for cardiomyopathies, arrhythmias, or aortic vascular disease is unproven and not medically necessary due to insufficient evidence; does not apply to chromosome microarray analysis for isolated severe congenital heart disease.

Genetic testing for coronary artery disease (CAD) is unproven and not medically necessary (includes gene expression tests, microarray or other genetic profiles for cardiac disease risk such as Cardiac DNA Insight, Cardio IQ gene tests and panels).

inv-05: LQTS - Covered when clinical criteria met

LQTS - testing recommendations from expert consensus

LQTS_index_testing: Molecular genetic testing for definitive disease-associated genes (KCNQ1, KCNH2, SCN5A, CALM1, CALM2, CALM3) should be offered to index patients with a high probability diagnosis of LQTS based on clinical history, family history, and ECG characteristics (Schwartz Score >= 3.5).Schwartz Score >= 3.5

Includes baseline, Holter, and exercise stress test ECG characteristics

LQTS_gene_specific: Analysis of specific genes should be offered for syndromic presentations (KCNQ1 and KCNE1 for Jervell and Lange-Nielsen; CACNA1C for Timothy syndrome; KCNJ2 for Andersen-Tawil; TRDN for triadin knockout). CACNA1C and KCNE1 may be analyzed in high-probability index patients.clinical diagnosis per cardiologist

Variant-specific testing recommended for relatives; predictive testing in children from birth onward

inv-06: CPVT - Covered when diagnostic criteria met or considered

CPVT - testing recommendations and considerations

CPVT_definitive_genes: Molecular genetic testing is recommended for patients satisfying diagnostic criteria for CPVT for established definite/strong evidence genes (RYR2, CASQ2, CALM1-3, TRDN, TECRL).CPVT diagnostic criteria (e.g., score > 3.5)

Variant-specific testing recommended for family members; predictive testing in children from birth onward

CPVT_modest_or_phenocopy: In phenotype-positive patients negative for established genes, testing may be considered for phenocopy genes (KCNJ2, SCN5A, PKP2); in modest phenotypes (CPVT score >=2 and <3.5) testing of established genes may be considered.CPVT diagnostic score >=2

Clinical utility for probands limited per Hayes; probable utility for cascade testing

inv-07: Brugada syndrome - Conditional/limited coverage stance

Brugada syndrome - guidance summary

BrS_testing_considerations: Genetic testing yields variants in 25-35% of high-suspicion BrS cases (most commonly SCN5A); professional evaluations indicate insufficient evidence that testing improves outcomes for probands, with limited evidence supporting testing in family members. Testing may be considered when characteristic type I ECG (spontaneous or induced) is present with supporting clinical features or family history.clinical criteria including characteristic ECG with at least one clinical feature

SCN5A variants may be associated with higher event risk; rare or disputed genes should not be reported routinely

inv-08: SQTS - Limited/targeted testing recommended

Short QT syndrome (SQTS) - gene validity considerations

SQTS_gene_focus: Due to extreme rarity and limited evidence, testing should focus on genes with stronger validity (KCNH2 definitive; KCNQ1, KCNJ2, SLC4A3 strong-moderate). Commonly included calcium-channel genes have sparse evidence and often yield VUS; evidence-based gene selection is recommended.clinical suspicion of SQTS

Limit panel breadth to reduce VUS burden

inv-09: Inherited AF - Conditional testing for early-onset cases

Inherited atrial fibrillation (AF) - testing guidance

Inherited AF_early_onset: Genetic testing may be considered in early-onset AF (e.g., age <45) without clear risk factors; testing targeted to rare pathogenic variants (e.g., TTN, MYH7, MYH6, LMNA, KCNQ1) and counseling/monitoring for cardiomyopathy or arrhythmia syndromes is reasonable.AF before age 45 without clear risk factors

Polygenic risk scores and common variant panels are not currently recommended for routine clinical use

inv-10: LQTS — Covered when ALL of the following are met

Covered when ALL of the following are met

LQTS_index_testing: Molecular genetic testing for definitive LQTS genes (KCNQ1, KCNH2, SCN5A, CALM1-3) is offered to index patients with a high-probability diagnosis of LQTS based on clinical history, family history, and ECG characteristics (Schwartz Score >= 3.5).Schwartz Score >= 3.5

Include syndromic gene analysis as clinically indicated

LQTS_family_testing: Variant-specific genetic testing is recommended for family members following identification of a disease-causing variant; predictive testing in related children is recommended from birth onward.any age for predictive testing

inv-11: CPVT — Covered when ANY of the following apply

Covered when ANY of the following apply (criteria reflect recommended vs optionally considered testing)

CPVT_definite: Patients meeting diagnostic criteria for CPVT (Class 1 diagnosis or CPVT diagnostic score > 3.5) — testing of RYR2, CASQ2, CALM1-3, TRDN, TECRL is recommended.CPVT diagnostic score > 3.5

Variant-specific family testing and predictive testing in children from birth onward

CPVT_modest: Patients with modest phenotype (CPVT score >=2 and <3.5) — testing of established CPVT genes may be considered.>=2 and <3.5

CPVT_phenocopy: Phenotype-positive CPVT patients negative for established genes — consider testing for phenocopy genes (KCNJ2, SCN5A, PKP2).phenotype-positive but gene-negative

inv-12: Brugada Syndrome (BrS) — Covered when ALL of the following are met

Covered when ALL of the following are met

BrS_SCN5A: Sequencing of SCN5A is recommended for an index BrS case with a type I ECG (spontaneous or induced) and supporting clinical features or family history.type I ECG

BrS_reporting_limits: Rare variants in genes with disputed or refuted gene-disease validity should not be routinely reported for BrS diagnostic testing.

Targeted sequencing of ultra-rare SCN5A VUS may be considered with family phenotyping for segregation analysis.

BrS_family_testing: Variant-specific testing recommended for relatives; predictive testing of pathogenic SCN5A variants in children recommended from birth onward.any age for predictive testing

inv-13: Short QT Syndrome (SQTS) — Covered when ALL of the following are met

Covered when ALL of the following are met

SQTS_definitive: Patients meeting diagnostic criteria for SQTS (diagnostic score > 4) — molecular testing recommended for definitive genes KCNH2 and KCNQ1.SQTS diagnostic score > 4

Testing of KCNJ2 and SLC4A3 may be performed in high-probability cases.

SQTS_family_testing: Variant-specific testing recommended for family members following identification of a disease-causative variant; predictive testing in related children may be considered in specific settings.

inv-14: Familial Atrial Fibrillation — Covered when ALL of the following are met

Covered when ALL of the following are met

FamilialAF_index: Index patients with familial (young, age <60) AF diagnosed on clinical criteria — testing of SCN5A, KCNQ1, MYL4 and truncating TTN variants may be performed.age < 60

Common variant or PRS testing for AF risk is not recommended for routine clinical use.

FamilialAF_family: Variant-specific testing may be recommended for family members and predictive testing in related children may be considered in specific settings.

inv-15: Hypertrophic Cardiomyopathy (HCM) — Covered when ALL of the following are met

Covered when ALL of the following are met

HCM_clinical_diagnosis: Clinical diagnosis of HCM based on non-dilated left ventricle with wall thickness >=13-15 mm in adults by echocardiogram or MRI and exclusion of other causes of LVH.wall thickness >=13-15 mm

HCM_index_testing: Genetic testing is supported for index patients meeting clinical diagnosis; initial testing should include genes with definitive/strong evidence (e.g., MYH7, MYBPC3, TNNI3, TNNT2, TPM1, MYL2, MYL3, ACTC1).

Detection rates vary by age and family history; testing is phenotype-driven.

HCM_family_testing: Variant-specific cascade testing for relatives of genotype-positive probands is endorsed; predictive testing and family screening are supported to manage risk and follow-up.

Genetic counseling recommended; obtain three-generation family history.

inv-16: Arrhythmogenic Cardiomyopathy (ACM) — Covered when ALL of the following are met

Covered when ALL of the following are met

ACM_genetic_role: Identification of a LP/P variant is a major diagnostic criterion for ACM subtypes; genetic testing supports diagnosis and cascade screening (common genes include DSC2, DSG2, DSP, JUP, PKP2, TMEM43).

Genetic testing useful for confirmatory testing of index cases and cascade screening of families.

inv-17: Familial Dilated Cardiomyopathy (DCM) — Covered when ALL of the following are met

Covered when ALL of the following are met

DCM_genetic_testing: Genetic testing for familial DCM is supported when clinical/family features suggest hereditary DCM; testing identifies mutations in a substantial subset of cases with TTN accounting for ~20%.

Targeted gene evaluation recommended based on phenotype and family history.

DCM_SCN5A_considerations: For SCN5A-associated DCM, phenotype recognition (multifocal VPD-predominant cardiomyopathy) guides testing and may inform therapeutic options (sodium channel blockers reported effective in some cases).

inv-18: Covered genetic testing indications and related requirements

Covered when ALL of the following are met (per guideline recommendations summarized):

Proband_testing: Genetic testing is recommended in probands with a confirmed diagnosis of cardiomyopathy or channelopathy (Class I/strong recommendation).

Sources: guideline statements (HFSA, ACC/AHA, EHRA/HRS)

DCM_high_yield_indications: For DCM: testing recommended for probands with family history of DCM, family history of premature unexpected sudden death, or patients with severe systolic dysfunction (LVEF <35%), malignant arrhythmia phenotype, younger age, or clinical features suggesting specific genetic disease.LVEF < 35%

EHRA/HRS and ACC/AHA guidance

LVNC_testing: Genetic testing may be useful when a cardiologist has established clinical diagnosis of LVNC or when LVNC is associated with syndromic features; do not test isolated incidental LVNC with normal LV function and no family history.

inv-19: Genetic testing and family screening

Covered when the following guideline-recommended conditions are met

Cardiomyopathy_testing_workflow: Obtain a 3-generation family history and pedigree; refer to expert centers for genetic/familial or unexplained cardiomyopathy; perform genetic testing in patients with cardiomyopathy; test the most clearly affected family member; provide genetic counseling; perform cascade testing of at-risk relatives for P/LP variants.

HFSA/ACMG and ACC/AHA guidance

LVNC_guidance: If proband has a disease-causing gene variant, first-degree relatives should undergo clinical screening and genetic counseling/testing; in individuals with pathologic LVNC, genetic counseling and testing are reasonable for diagnosis and cascade screening.

HRS recommendations

HTAD_testing: Obtain multigenerational family history for individuals with aortic root/ascending aneurysm or dissection; perform genetic testing to identify P/LP variants in individuals with risk factors for HTAD; provide gene-directed management and cascade testing for at-risk relatives when a P/LP variant is identified.

ACC/AHA 2022 guideline and ClinGen gene lists

inv-20: Overall coverage determination

Policy stance summary and exception

Policy_level_stance: Genetic testing for cardiomyopathies, arrhythmias, or aortic vascular disease listed as medically necessary in the policy are covered; all other genetic testing for these conditions is unproven and not medically necessary due to insufficient evidence of efficacy, except chromosome microarray analysis for isolated severe congenital heart disease.

Derived from Policy History/Revision Information and Instructions for Use

Chromosome microarray analysis (CMA) for isolated severe congenital heart disease is explicitly exempted from the policy statement that classifies other genetic testing as unproven. In other words, while the policy considers all other genetic testing for cardiomyopathies, arrhythmias, or aortic vascular disease that is not listed as medically necessary to be unproven and not medically necessary, this exclusion does not apply to CMA performed for isolated severe congenital heart disease. Providers should refer to the related Medical Policy on Chromosome Microarray Testing (Non‑Oncology Conditions) for Idaho‑specific coverage details when CMA is being considered for such congenital heart disease cases.

Recent evidence reappraisals have reclassified multiple genes previously associated with inherited arrhythmia syndromes as having limited or disputed clinical validity. The policy follows these evidence-based evaluations and states that variants in genes reclassified as limited or disputed should not be used for clinical decision-making unless new, robust evidence emerges. Consequently, broad panels that include such genes are discouraged because they can increase the rate of variants of uncertain significance without improving diagnostic yield and may confound care decisions.

For Brugada syndrome (BrS), the policy limits routine reporting and searching of rare variants in genes whose gene–disease validity has been disputed or refuted. Genetic testing for BrS focuses on SCN5A sequencing for index cases with a type I ECG and recommends that variants from genes with disputed validity not be reported routinely for diagnostic testing. Targeted evaluation of very rare SCN5A VUS (population allele frequency < 1×10-5) can be considered only with concurrent family phenotyping and segregation analysis after genetic counseling.

The policy states that searching for common genetic variants associated with atrial fibrillation (AF) risk is not clinically useful at present. Expert consensus notes that routine testing for common AF‑associated variants or using such common‑variant searches for clinical decision‑making is not recommended because they have not been shown to improve prediction or management beyond conventional clinical assessment.

Genetic testing is not recommended for isolated, incidental left ventricular noncompaction (LVNC) when left ventricular function is normal, there are no syndromic features, and there is no relevant family history. In these scenarios the policy explicitly advises against testing because clinical utility is lacking; testing may be appropriate only when a cardiologist has established a pathologic LVNC phenotype or when syndromic or familial features are present.

The policy notes that some copy number variants (CNVs) associated with thoracic aortic aneurysm/dissection (TAAD) may not be detectable by next‑generation sequencing (NGS) alone. Studies cited show that panels testing all individuals with TAAD can have lower diagnostic yield compared with testing focused on those with suggestive family history, in part because several CNVs in TAAD cohorts were only detectable by additional methods (e.g., microarray). Providers should recognize that panel composition and methodology affect CNV detection and diagnostic yield for TAAD.

The Sixth Joint Task Force (European Society of Cardiology and other societies) concluded that routine use of genetic markers for predicting coronary heart disease (CHD) is not recommended. The task force highlighted a lack of consensus on which markers to include, how to calculate genomic risk scores, and how to apply such information for prevention, and therefore advised against using genetic markers for CHD prediction in routine clinical practice.

Outside of the specific covered indications enumerated in this policy, genetic testing for cardiomyopathies, arrhythmias, or aortic vascular disease that is not listed as medically necessary is considered unproven and not medically necessary due to insufficient evidence of clinical efficacy. The policy revision clarifies this scope and explicitly states an exception for chromosome microarray analysis in isolated severe congenital heart disease; for all other requests, coverage should be determined against the policy’s listed medically necessary indications and referenced guidance.

Genetic tests and gene‑expression or polygenic risk tests intended to predict coronary artery disease (CAD) are considered unproven and not medically necessary. The policy specifically includes gene expression tests, microarray or other genetic profile tests, and named commercial examples reported under PLA/U codes or CPT 81493. These modalities lack sufficient evidence of clinical utility for routine CAD risk assessment and thus are not supported for coverage under the policy.

The policy discourages routine use of very large, unselected multi‑gene panels that include genes reclassified as limited or disputed, or use of panels when required clinical criteria are not met. Such broad panels increase variants of uncertain significance without demonstrated outcome benefit. Genetic testing should be phenotype‑driven, focusing on genes with established validity for the suspected condition; panels that indiscriminately include genes of limited/disputed evidence are not recommended for clinical decision‑making.

For inherited arrhythmic diseases the policy requires an appropriate diagnostic phenotype—most notably a diagnostic ECG—for testing to be appropriate. Ordering genetic testing in the absence of a diagnostic ECG or other phenotype meeting guideline‑based criteria is not recommended because clinical utility is dependent on pre‑test probability and phenotype‑driven evaluation.

Cascade (predictive) testing of relatives is appropriate only when a pathogenic or likely pathogenic (P/LP) variant has been identified in the proband. The policy states that cascade testing is not useful and is not recommended when the proband’s testing identified no P/LP variant; targeted family testing should follow identification of a disease‑causing variant in the index case.

The policy states that use of genomic risk scores (polygenic risk scores) or gene expression testing for coronary artery disease is not supported by sufficient evidence for clinical utility. Current data do not show consistent improvement in risk prediction or clinical outcomes compared with established clinical risk algorithms, and therefore these tests are considered investigational and not medically necessary for routine CAD risk assessment.

The American Heart Association notes that whether polygenic risk score (PRS) information is clinically actionable and can meaningfully change medical management remains to be determined. The policy cites this expert position to support the stance that PRS and similar genomic risk markers have undefined clinical actionability and are not currently established for routine use in clinical decision‑making.

Reiterating the overall policy scope, genetic testing for cardiomyopathies, arrhythmias, or aortic vascular disease that is not explicitly listed as medically necessary in the policy is considered unproven and not medically necessary. Providers should consult the policy’s covered indications and referenced guidelines when evaluating test appropriateness; the policy’s exception for chromosome microarray analysis for isolated severe congenital heart disease remains in effect.

Detailed Covered Indications

inv-90: Inherited arrhythmia syndromes (Brugada, CPVT, LQTS with specified criteria, SQTS) — index-case testing indications

Index_case_arrhythmia_indications: Index-case testing indications: Brugada syndrome with diagnostic ECG features; CPVT meeting diagnostic criteria; LQTS index patients meeting specified ECG/Schwartz subcriteria; SQTS meeting diagnostic criteria.

Refer to condition-specific criteria for gene targets and testing approach

inv-91: Hereditary cardiomyopathies — index-case testing indications

Index_case_cardiomyopathy_indications: Index-case testing indications: ARVD/C meeting diagnostic criteria; DCM without identifiable cause with conduction disease or family sudden death ≤45; HCM without identifiable cause; LVNC when clinically diagnosed.

Test the most clearly affected family member first

inv-92: Confirmed or suspected thoracic aortic disease — index-case testing indications

Coding and Diagnostic Thresholds

Applicable CPT/PLA Codesmixed

0237U	Cardiac ion channelopathies (e.g., Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia), genomic sequence analysis panel including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A
0401U	Cardiology (coronary heart disease [CHD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score for a coronary event
0439U	Cardiology (coronary heart disease [CHD]), DNA, analysis of 5 single-nucleotide polymorphisms (SNPs) and 3 DNA methylation markers, qPCR and digital PCR, whole blood, algorithm reported as a 4-tiered risk score for a 3-year risk of symptomatic CHD
0440U	Cardiology (coronary heart disease [CHD]), DNA, analysis of 10 single-nucleotide polymorphisms (SNPs) and 6 DNA methylation markers, qPCR and digital PCR, whole blood, algorithm reported as detected or not detected for CHD
0466U	Cardiology (coronary artery disease [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 (e.g., FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, 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

No explicit CPT/HCPCS/ICD codes in this document portionmixed

No codes listed

Schwartz Score categories — interpretation

Low probabilitySchwartz Score ≤ 1.0

Intermediate probabilitySchwartz Score 1.5–3.0

High probability (most actionable)Schwartz Score ≥ 3.5

QTc interval diagnostic threshold

Male diagnostic QTc threshold> 470 msec

Female diagnostic QTc threshold> 480 msec

Context

Provider Actions, Documentation, and Authorization

Note

Applicable Codes

The following codes are provided for reference only. Inclusion does not imply coverage or guarantee payment; verify benefits and applicable federal/state/contractual rules.

Applicable procedure and diagnosis codes listed in policy code tables (see policy).

Prior Authorization

Prior Authorization — Phenotype and Guideline Basis

Genetic testing for inherited cardiovascular disorders is intended to be driven by phenotype and guideline-based diagnostic criteria. Prior authorization may be required by the member’s benefit plan; when required, authorization should be supported by documented phenotype, diagnostic scores, family history, and relevant testing results.

Prior authorization implied when the benefit plan requires it — check member benefit, federal/state/contractual requirements, and use third-party tools as available (e.g., InterQual®).
Prior authorization decisions should be supported by clinical documentation including phenotype and diagnostic scores (see arrhythmia- and cardiomyopathy-specific documentation guidance).

Not Covered / Unproven Tests

Genetic testing modalities and specific commercial tests intended to assess coronary artery disease risk—including gene expression profiling, microarray‑based profiles, and polygenic risk algorithms (examples listed under PLA/U codes and CPT 81493)—are described in the policy as not covered because they lack sufficient evidence of improved clinical outcomes. The Applicable Codes section enumerates representative U‑codes and CPT codes for these tests; inclusion in the code list does not imply coverage, and these CAD‑related genomic tests are explicitly listed as unproven in this policy.

The policy designates use of genes with limited or disputed evidence, and very large unselected gene panels that include such genes, as not covered for routine clinical decision‑making. Evidence‑based gene reappraisals for LQTS, CPVT, and SQTS demonstrate that many previously reported genes have limited support; using them without clear phenotype or updated validation increases VUS rates and uncertain clinical interpretations and therefore is discouraged.

Reporting or actively searching for variants in genes with disputed or refuted validity for Brugada syndrome and conducting common‑variant searches for atrial fibrillation risk are both designated as not covered. For BrS, only validated gene findings (not disputed‑validity genes) should inform diagnostic testing; for AF, common‑variant searching lacks demonstrated clinical utility and is not supported.

Genomic risk scores and gene expression tests for coronary artery disease are identified in the policy as not covered due to insufficient evidence of clinical utility. The policy references systematic reviews and cohort studies that fail to demonstrate consistent improvement in prediction or patient outcomes when these genomic approaches are added to standard clinical risk models.

The policy references expert consensus that does not support universal or routine use of DNA tests for determining cardiovascular risk. The Sixth Joint Task Force concluded that absence of consensus on markers, score calculation, and preventive actions means genomic testing for CHD risk should not be used broadly in clinical practice, and such testing is therefore not covered.

Eligibility and Preconditions for Testing

A family history of sudden cardiac death in a first‑ or second‑degree relative at age ≤45 is an example of a family‑history criterion that supports consideration of genetic testing for dilated cardiomyopathy (DCM). This type of familial event increases pre‑test probability and is specifically referenced in guideline‑based indications for DCM genetic evaluation.

Provider Support and Counseling

Documentation Required

Offer and document genetic counseling for index patients and relatives

Guidelines recommend offering genetic counseling for patients being considered for genetic testing, particularly index patients and relatives; document counseling and referrals in the medical record.

Provide genetic counseling prior to family cascade testing and when reporting variants to support informed decision‑making.
Document counseling content, who provided it, and any referrals to genetics experts or centers.

Documentation Required

Document counseling per guideline recommendations

Professional guidance repeatedly emphasizes offering genetic counseling for patients considered for testing; include counseling in care plans and document it when performed.

Genetic counseling is recommended for all patients with cardiomyopathy and their family members (Level A evidence where noted).
Document counseling uptake and any decisions regarding timing of testing for children.

Definitions and Terminology

First‑Degree Relative

DefinitionFirst‑degree relatives include parents, siblings, and offspring (NCCN).

Clinical relevanceUsed to identify individuals for cascade clinical screening and genetic testing when a familial P/LP variant is identified.

ScopeApplies to family-history collection and pedigree construction recommendations.

Multi‑Gene Panel

DefinitionMulti‑gene panel: genetic tests using next‑generation sequencing to test multiple genes simultaneously (NCI Dictionary).

Typical usePanels used for inherited arrhythmias and cardiomyopathies to assess multiple candidate genes at once.

Coding, Prior Authorization, and Denial Risk Highlights

Denial Risk

Non‑covered tests subject to denial and benefit review

Claims for genetic testing not listed as medically necessary are subject to denial and benefit review; ordering outside the policy‑listed indications risks non‑coverage.

Verify that the indication is listed as medically necessary in the policy before ordering.
Expect denial risk for genomic risk scores and CAD genetic profiling, which are considered unproven.

Billing Rule

Code list is informational — verify coverage/authorization

Applicable procedure and PLA codes are listed for reference only; the list does not imply coverage or prior authorization status — verify benefits prior to ordering.

Policy Revision History and Changes

2026-05-01policy_revisionLatest

Revised 'Not medically necessary' language to clarify that all other genetic testing for cardiomyopathies, arrhythmias, or aortic vascular disease not listed as medically necessary is unproven and not medically necessary, with an explicit exception for chromosome microarray analysis for isolated severe congenital heart disease; updated Related Policies to add a referenced link; refreshed supporting sections (Description of Services, Clinical Evidence, FDA, References); archived previous version CS048ID.C.

When using this policy to determine coverage, verify federal, state, and contractual benefit plan requirements as they may differ from standard policy language. The policy is informational and UnitedHealthcare may apply third‑party tools or plan‑specific rules when administering benefits; consult plan documents and local requirements before authorizing testing.

Policy Summary

PayerUnitedHealthcare

PolicyGenetic Testing for Cardiac Disease (for Idaho Only)

Policy CodePolicy CS048ID.D

Change TypeClarificationRelated link added

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionVerify guideline-based diagnostic criteria and document phenotype (e.g., Schwartz Score, ECG, family history) when requesting genetic testing; confirm benefit/prior authorization per plan.

SourceLink

On This Page

CPVT_family_testing: Variant-specific genetic testing is recommended for family members when a P/LP variant is identified; predictive testing in related children recommended from birth onward.any age for predictive testing

HCM_testing: In HCM probands, genetic testing of genes with definitive/strong evidence (e.g., MYH7, MYBPC3, TNNI3, TNNT2, TPM1, MYL2, MYL3, ACTC1) is recommended to identify at-risk relatives; obtain three-generation family history and provide genetic counseling.

AHA/ACC HCM recommendations

Cascade_predictive_testing: Variant-specific predictive testing is recommended for at-risk family members when a pathogenic/likely pathogenic variant is identified in the proband; cascade testing and clinical screening (ECG, echo) of first-degree relatives recommended.

HFSA/ACMG and guideline statements

Pediatric_testing_considerations: Predictive genetic testing in related children is recommended in those aged >10-12 years and may be considered below that age for families with early-onset disease; timing should be individualized with counseling.age >10-12 years

Guideline-based recommendations

Variant_reclassification_follow_up: Serial re-evaluation of variant significance is recommended to assess for reclassification that could impact diagnosis and family testing; focused phenotyping and surveillance recommended when ACMG-designated secondary finding cardiomyopathy genes are reported.

AHA/ACC and HFSA/ACMG statements

Index_TAAD_indications: Index-case testing indications: individuals with aortic root/ascending aortic aneurysm or dissection and risk factors for HTAD; obtain multigenerational family history and consider testing of validated HTAD genes.

Panels typically include ClinGen/ACC-AHA listed genes (e.g., FBN1, TGFBR1/2, COL3A1, ACTA2)

inv-93: Index patients with high-probability LQTS (Schwartz Score >= 3.5) for definitive LQTS genes

High_prob_LQTS_index: Index patients with high-probability LQTS (Schwartz Score >= 3.5) — testing of definitive LQTS genes (KCNQ1, KCNH2, SCN5A, CALM1-3); include syndromic gene analysis as indicated; variant-specific testing for relatives.Schwartz Score >= 3.5

Predictive testing in children from birth onward

inv-94: Patients meeting diagnostic criteria for CPVT for established CPVT genes

CPVT_diagnostic_patients: Patients meeting diagnostic criteria for CPVT — molecular testing for established CPVT genes RYR2, CASQ2, CALM1-3, TRDN, TECRL; variant-specific testing for relatives.CPVT diagnostic score > 3.5

Predictive testing in children from birth onward

inv-95: Early-onset AF (<45) without risk factors — testing for selected rare pathogenic variants

Early_onset_AF_testing: Early-onset AF (<45) without risk factors — consider genetic counseling and testing for rare pathogenic variants (e.g., TTN, MYH7, MYH6, LMNA, KCNQ1) and monitoring for cardiomyopathy/arrhythmia syndromes.age <45

PRS and common-variant panels not recommended for routine clinical use

inv-96: Index patients with high probability LQTS — testing of definitive genes

LQTS_definitive_genes: Index patients with high probability LQTS — testing of definitive genes (KCNQ1, KCNH2, SCN5A, CALM1-3); include syndromic genes as clinically indicated.Schwartz Score >= 3.5

Variant-specific testing for relatives

inv-97: Patients meeting CPVT diagnostic criteria — testing of established genes

CPVT_definitive_gene_testing: Patients meeting CPVT diagnostic criteria — testing of RYR2, CASQ2, CALM1-3, TRDN, TECRL; consider phenocopy genes if index negative.CPVT diagnostic score > 3.5

Variant-specific family testing recommended

inv-98: Index BrS cases with type I ECG — sequencing of SCN5A

BrS_SCN5A_index: Index BrS cases with type I ECG (spontaneous or induced) and supporting clinical features — sequencing of SCN5A is recommended.type I ECG

Rare/disputed genes should not be routinely reported

inv-99: Patients meeting SQTS diagnostic criteria — testing of KCNH2 and KCNQ1

SQTS_gene_recommendations: Patients meeting SQTS diagnostic criteria (score > 4) — testing of KCNH2 and KCNQ1 recommended; consider KCNJ2 and SLC4A3 in high-probability index patients.SQTS diagnostic score > 4

Limit inclusion of genes with sparse evidence to reduce VUS

inv-100: Clinically diagnosed HCM — sarcomeric gene testing

HCM_clinical_index: Clinically diagnosed HCM (LV wall thickness >=13-15 mm) — sarcomeric gene testing (initial tier: MYH7, MYBPC3, TNNI3, TNNT2, TPM1, MYL2, MYL3, ACTC1) is recommended.wall thickness >=13-15 mm

Obtain family history and genetic counseling

inv-101: ACM/ARVC index cases — testing of desmosomal and ACM-associated genes

ACM_ARVC_testing: ACM/ARVC index cases meeting diagnostic criteria — testing of desmosomal and ACM-associated genes (e.g., PKP2, DSP, DSG2, DSC2, JUP, TMEM43) is recommended to support diagnosis and cascade screening.

Identification of LP/P variant is a major diagnostic criterion

inv-102: Familial DCM — testing including TTN, MYH7 and other DCM-associated genes

Familial_DCM_testing: Familial DCM with suggestive clinical/family features — testing including TTN, MYH7 and other DCM-associated genes (initial tier includes BAG3, DES, FLNC, LMNA, MYH7, PLN, RBM20, SCN5A, TNNC1, TNNT2, TTN, DSP).

Variant-specific testing for relatives recommended when P/LP variant identified

inv-103: Probands with confirmed/suspected inherited cardiomyopathy and at-risk relatives

Probands_and_at_risk_relatives: Probands with confirmed or suspected inherited cardiomyopathy (HCM, DCM, ACM, LVNC) and at-risk relatives after identification of familial P/LP variant — variant-specific predictive testing and cascade clinical screening are recommended.

Includes presymptomatic individuals with strong family history; test most clearly affected family member first

inv-104: Patients with primary cardiomyopathy and individuals with aortic root/ascending aneurysms

Cardiomyopathy_pediatric_and_TAAD: Patients with primary cardiomyopathy including pediatric-onset, and individuals with aortic root/ascending aortic aneurysms or dissection with HTAD risk factors — genetic testing and family history evaluation recommended; test most clearly affected family member and perform cascade testing for identified P/LP variants.

Refer to expert centers as needed

inv-105: Individuals with clinical LVNC for diagnosis and family screening

LVNC_indications: Individuals with clinical LVNC (pathologic LVNC) — genetic testing for diagnosis and family screening is reasonable when cardiologist has established diagnosis or when syndromic features are present; do not test isolated incidental LVNC with normal LV function and no family history.

HRS and HFSA guidance

inv-106: Inherited cardiovascular diseases where single-gene pathogenic variants are suspected

Single_gene_suspected_conditions: Inherited cardiovascular diseases and conditions where single-gene pathogenic variants are suspected (channelopathies, cardiomyopathies) — genetic testing is indicated per guideline-directed, phenotype-driven approach.

Expert statements emphasize genetics role and clinician genetics competencies; PRS utility for complex CAD remains debated

inv-107: Genetic testing indications listed as medically necessary are covered

Policy_medical_necessity_summary: Genetic testing indications listed as medically necessary in the full policy are covered; this excerpt does not include the full detailed list — refer to full policy for specifics.

See Policy History/Revision Information

Prolonged QTc on ECG is diagnostic in appropriate clinical context

Diagnostic score thresholds

LQTS diagnostic scoreSchwartz Score ≥ 3.5 (high probability)

CPVT definite thresholdCPVT diagnostic score > 3.5 (Class 1 clinical diagnosis)

CPVT modest-phenotype considerationCPVT diagnostic score ≥ 2 and < 3.5 — testing may be considered

LQTS diagnostic threshold

LQTS high-probability threshold (actionable)Schwartz Score ≥ 3.5 — indicates molecular testing of definitive LQTS genes (KCNQ1, KCNH2, SCN5A, CALM1-3)

Use with ECG and clinical historyDiagnosis based on clinical history, family history, and ECG characteristics (baseline, Holter, exercise)

Syndromic gene analysisConsider gene-specific testing for syndromic presentations (e.g., KCNE1, CACNA1C, KCNJ2, TRDN)

CPVT diagnostic thresholds

Definite/diagnostic threshold (CPVT)Class 1 clinical diagnosis or CPVT diagnostic score > 3.5 — molecular testing recommended for definitive genes (RYR2, CASQ2, CALM1-3, TRDN, TECRL)

Modest phenotypeCPVT diagnostic score ≥ 2 and < 3.5 — testing of established genes may be considered

Phenocopy testingPhenotype-positive but gene-negative patients may be tested for phenocopy genes (KCNJ2, SCN5A, PKP2)

SQTS diagnostic threshold

SQTS diagnostic threshold (definitive)SQTS diagnostic score > 4 — molecular testing recommended for definitive genes KCNH2 and KCNQ1

Expanded gene considerationKCNJ2 and SLC4A3 may be tested in index patients with high-probability SQTS

Testing contextDiagnosis based on clinical history, family history, and ECG characteristics (baseline/Holter/exercise)

Not applicable

Not applicableNo applicable thresholds or definitions in provided excerpt

Note

Prior Authorization Not Specified in Policy

This policy does not specify a universal prior authorization process. Providers must verify whether prior authorization or other pre-service requirements apply under the member’s specific plan and comply with applicable federal/state/contractual rules.

No explicit universal prior authorization requirements are stated in this policy text; benefit verification is required.
UnitedHealthcare may use external tools and plan documents to determine preauthorization needs.

Denial Risk

Clinical Criteria and Denial Risk

Coverage is contingent on meeting clinical criteria. Tests lacking required clinical documentation or performed without a phenotype meeting diagnostic criteria are at increased risk of denial.

Clinical-criteria-dependent coverage risk — lack of phenotype or diagnostic ECG for inherited arrhythmic disease increases denial risk.
Denial risk for non-covered genetic testing — claims for tests not listed as medically necessary are subject to denial and benefit review.

Note

Use of Genetic Markers in CHD Prediction

Use of genetic markers or genomic risk scores for routine prediction of coronary heart disease (CHD) is not recommended. The Sixth Joint Task Force concluded there is no consensus on markers, score calculation, or preventive use; therefore use of genetic markers in CHD prediction is not recommended.

Genomic risk scores/PRS for CHD currently lack consensus for clinical implementation and are not endorsed as a predictive standard.

Documentation Required

Medical Records and Required Clinical Documentation

The patient’s medical record must include documentation that fully supports the medical necessity of requested genetic testing. Documentation should be legible, maintained in the medical record, and available upon request.

Required clinical documentation includes: relevant medical history, multigenerational family history (≥3 generations when applicable), physical examination, imaging reports (e.g., echocardiogram, MRI), ECG/holter/exercise testing results, diagnostic scores (e.g., Schwartz score, CPVT/SQTS scores), and any specialty clinic notes (cardiology/genetics).
Documentation and benefit-plan alignment — documentation must align with federal/state/contractual benefit plan requirements when determining coverage.

Documentation Required

Clinical Documentation for Arrhythmia Testing

For inherited arrhythmia testing (e.g., LQTS, CPVT, BrS, SQTS, familial AF), genetic testing should be considered and prior authorization supported only when phenotype and diagnostic testing support the diagnosis.

Arrhythmia-specific documentation: clinical history, family history, baseline ECG characteristics, Holter/ambulatory monitoring, exercise stress testing results, and diagnostic scores (e.g., Schwartz Score for LQTS).
Genetic testing for Brugada syndrome is recommended when a Type I ECG is present (spontaneous or drug-provoked) with supporting clinical features or family history.
Testing for inherited arrhythmias is intended to be driven by pre-test probability; testing without a diagnostic ECG or phenotype is discouraged and may be denied.

Documentation Required

Documentation for HCM and Cardiomyopathy Testing

For hypertrophic cardiomyopathy (HCM) and related cardiomyopathies, documentation should include imaging evidence and family history to support genetic testing.

Documentation for HCM testing: echocardiogram or MRI demonstrating left ventricular hypertrophy (wall thickness ≥13–15 mm in adults), exclusion of secondary causes (e.g., hypertension, valvular disease), and relevant family history.
Obtain focused cardiovascular phenotyping when pathogenic/likely pathogenic (P/LP) variants are identified and provide genetic counseling as recommended.

Note

Cascade Testing and Initial Family Screening

Cascade testing and initial family screening are recommended when a pathogenic or likely pathogenic variant is identified in a proband. Test the most clearly affected family member first; then perform targeted variant-specific testing of at-risk relatives.

Cascade genetic testing recommended for first-degree relatives when a P/LP variant is identified.
Initial family screening for cardiomyopathy should include ECG and echocardiography as first-line cascade evaluation.
Predictive genetic testing in children: follow gene- and disease-specific guidance (some conditions support testing from birth; others recommend age thresholds such as >10–12 years).

Step Therapy

Step Therapy / Testing Sequence

This policy does not establish step therapy requirements. Targeted gene panels and variant-specific cascade testing are emphasized rather than stepwise testing protocols.

Not specified as step therapy — no explicit step therapy requirements stated here.

Note

Clinical Modeling Assumptions

Clinical modeling assumptions used in referenced studies (e.g., PRS analyses) may assume guideline-based interventions such as initiation of statin therapy when risk thresholds are met. These modeled interventions do not substitute for individualized clinical decision-making or coverage determinations.

Example assumption: PRS-based population modeling assumed initiation of statin therapy per guideline thresholds (e.g., 10-year risk ≥10% in some models).

The policy clarifies that an exception exists for chromosome microarray analysis performed for isolated severe congenital heart disease; all other genetic tests not specifically listed as medically necessary in this policy are classified as unproven and not medically necessary and therefore are not covered. Providers should consult the policy’s covered indications and related Idaho‑specific references when evaluating coverage for genetic testing requests.

Documentation Required

Provide pre‑ and post‑test counseling and document outcomes

Guidelines encourage pre‑ and post‑test counseling for HCM and other inherited cardiac conditions; ensure counseling occurs in advance of cascade testing and record counseling outcomes.

Counseling is associated with increased satisfaction and improved patient‑reported outcomes in many studies.
Record counseling sessions and any decisions made about cascade or predictive testing.

Documentation Required

Refer to expert centers for genetic counseling and document referrals

Guidelines recommend offering genetic counseling for patients and family members; when available, refer to expert centers and genetics professionals and document the referral and counseling.

Refer patients with genetic, familial, or unexplained cardiomyopathy to expert centers as appropriate.
Document referrals and any genetic counseling provided by specialists.

Documentation Required

Ensure counseling is offered and documented for testing decisions

Guidelines consistently recommend offering genetic counseling for individuals considered for genetic testing; record counseling and its timing relative to testing.

Document whether counseling was provided pre‑test and/or post‑test and by whom.
Include counseling notes in submissions supporting medical necessity.

Documentation Required

Include counseling documentation in genetic testing workflow

Guidelines recommend genetic counseling for patients with cardiomyopathy and their family members; include counseling documentation when seeking coverage or prior authorization.

Counseling is recommended as part of standard workflow for cardiomyopathy genetic evaluation.
Document counseling to support the medical necessity of testing and cascade evaluation.

Documentation Required

Counseling recommended but specific pre/post‑test mandates not specified in excerpt

Guidelines recommend genetic counseling for patients considered for genetic testing; the excerpt does not specify mandatory pre‑ or post‑test counseling requirements — refer to the full policy and the member’s plan for specific counseling requirements.

The policy excerpt directs users to referenced guidelines and benefit plan rules for detailed counseling requirements.
Verify plan‑specific counseling expectations prior to ordering.

Documentation Required

Ordering clinician not specified in excerpt; document clinician assessment

The excerpt does not specify which clinicians may order testing; guidelines reference cardiologist assessment and genetics professionals for establishing diagnoses and selecting gene analysis—verify plan rules for ordering privileges.

Testing is typically ordered in the context of cardiology or genetics evaluation; refer to the full policy or plan rules for who may order tests.
Document the clinician assessment supporting the testing decision.

Documentation Required

Document clinician assessment that justifies gene/panel selection

Clinician assessment (cardiologist or genetics specialist) should establish the clinical diagnosis and guide gene analysis decisions; document the assessment in the medical record to support testing.

Record the clinician’s diagnostic rationale and relevant phenotype details (ECG, imaging, family history).
Use the clinician assessment to justify gene/panel selection in prior authorization submissions.

Documentation Required

Use documented clinician assessment to support specific gene testing

Clinician assessment and documentation of the diagnosis are essential for deciding on specific gene analysis; include this information when ordering testing and in prior authorization materials.

Document the specific clinical features that map to the genes being ordered (e.g., type I BrS ECG for SCN5A sequencing).
Attach diagnostic test results and scores to the testing request.

Documentation Required

Order testing as part of counseling and clinical evaluation; refer to experts as needed

Order genetic testing within the context of genetic counseling and clinical evaluation; refer to expert centers when appropriate and document referrals and counseling.

Genetic testing should be part of a coordinated clinical and counseling workflow.
Document that testing decisions were made following counseling and clinical evaluation.

Documentation Required

Who may order testing not specified in excerpt — verify plan rules

The excerpt does not explicitly state who may order testing; verify plan‑specific rules and document the ordering clinician’s qualifications and rationale when submitting testing requests.

Check the full policy and the member’s plan for any ordering provider restrictions.
Include clinician credentials and role in the documentation when required.

Very large, unselected panels may increase VUS rates and include genes with limited/disputed evidence; choose evidence‑based panels.

Schwartz Score — definition and categories

DefinitionSchwartz Score: diagnostic scoring system for LQTS incorporating ECG findings, clinical history, and family history; maximum score = 9.

Categories≤1.0 = low probability; 1.5–3.0 = intermediate probability; ≥3.5 = high probability.

ComponentsIncludes QTc values, exercise-recovery QTc, torsades de pointes, T‑wave abnormalities, syncope, congenital deafness, and family history.

QTc diagnostic thresholds

Male QTc threshold> 470 ms (males)

Female QTc threshold> 480 ms (females)

Clinical note (actionable)Prolonged QTc by these thresholds on ECG is diagnostic in the appropriate clinical context

Schwartz Score ≥ 3.5 — high‑probability threshold

High-probability thresholdSchwartz Score ≥ 3.5 — denotes high probability of LQTS

ActionHigh-probability index patients should be offered molecular testing of definitive LQTS genes (KCNQ1, KCNH2, SCN5A, CALM1-3).

ContextApply after excluding acquired causes of QT prolongation and based on ECG and clinical/family history.

CPVT diagnostic score — definition and thresholds

CPVT definite thresholdClass 1 clinical diagnosis or CPVT diagnostic score > 3.5 — indicates molecular testing for established CPVT genes (RYR2, CASQ2, CALM1-3, TRDN, TECRL)

Modest phenotypeCPVT diagnostic score ≥ 2 and < 3.5 — testing of established genes may be considered

Phenocopy considerationPhenotype-positive but gene‑negative patients may be tested for phenocopy genes (KCNJ2, SCN5A, PKP2)

Index patient

Index patient definitionA proband or first‑identified individual with a high‑probability clinical diagnosis prompting molecular genetic testing.

RoleIndex patients are the preferred first individual to test genetically to enable targeted cascade testing in relatives.

Testing implicationTesting an index patient guides variant‑specific testing of relatives if a P/LP variant is identified.

Variant‑specific testing

DefinitionVariant‑specific testing: targeted testing of family members for a previously identified disease‑causing variant in the proband.

When usedRecommended for relatives after identification of a P/LP variant in the index case; allows focused, cost‑effective cascade testing.

Predictive testing in childrenPredictive testing in related children is recommended from birth onward for certain conditions (e.g., LQTS, CPVT) per guidance.

Left Ventricular Noncompaction (LVNC)

DefinitionLeft ventricular noncompaction (LVNC): cardiomyopathy where the left ventricle has a thick, spongy appearance due to abnormal development; presentations vary from asymptomatic to heart failure or sudden death.

Genetic relevanceVariants in MYH7 and MYBPC3 account for up to ~30% of cases; genetic diagnosis may inform prognosis.

Testing caveatGenetic testing is not recommended for isolated incidental LVNC with normal LV function and no family history.

Predictive genetic testing

DefinitionPredictive genetic testing: testing an asymptomatic at‑risk individual for a known familial pathogenic variant to guide surveillance and management.

UseAppropriate for first‑degree relatives when a P/LP variant is identified in the proband; combined with ECG and echocardiography in cascade screening.

Timing in childrenPredictive testing in related children is recommended from birth onward for some channelopathies; timing may vary for cardiomyopathies and should be individualized.

HFSA Levels of Evidence (A/B/C)

HFSA Level AHigh correlation with cardiomyopathic disease in moderate or large studies.

HFSA Level BHigh correlation in smaller or single‑center studies.

HFSA Level CCorrelation based on case reports; lower level evidence.

ACC/AHA Levels of Evidence (A/B/C)

ACC/AHA Level AData from multiple populations; multiple randomized trials or meta‑analyses.

ACC/AHA Level BLimited populations; single randomized or nonrandomized studies.

ACC/AHA Level C (most actionable)Very limited populations; consensus opinion, case studies, or standard‑of‑care guidance.

Genes linked to CAD — examples

Example CAD genesAPOB, LDLR, PCSK9

ContextThese genes are major contributors to familial hypercholesterolemia and CAD risk but PRS utility remains debated.

Policy stanceGenetic testing for CAD (including gene expression and PRS) is considered unproven for routine clinical use in this policy excerpt.

CLIA — laboratory regulation

CLIA regulationLaboratories performing genetic tests for cardiac disease are regulated under the Clinical Laboratory Improvement Amendments (CLIA) Act of 1988.

FDA noteFDA approvals/cleared devices are informational only and not a basis for coverage decisions.

ReferenceSee FDA and CLIA guidance links for details (policy references).

Multigene Test — definition (NCI)

Definition sourceMultigene Test definition referenced from the NCI Dictionary of Genetics Terms.

ImplicationUsed interchangeably with multi‑gene panel; refers to tests that evaluate multiple genes simultaneously.

Clinical useApplicable to panels for inherited arrhythmias and cardiomyopathies described in this policy.

Listing of codes (e.g., 81410, 81439, 81493, U‑codes) is informational and not a guarantee of coverage.
Check member plan rules and prior authorization requirements for any listed code.

Prior Authorization

Verify benefit/authorization requirements with member’s plan before ordering

Before ordering and submitting claims, check federal, state, and contractual benefit plan requirements for coverage and prior authorization; UnitedHealthcare may apply third‑party tools to help administer benefits.

Plan terms govern in the event of conflict with this policy; confirm plan‑specific authorization and documentation requirements.
Be prepared to supply requested documentation to support medical necessity during benefit review.