ModifiedUnitedHealthcarePolicy CS165NM.C

Genetic Testing for Neurological Disorders (for New Mexico Only)

Policy governing coverage of multi-gene genetic testing (panels of ≥5 genes) for heritable neurological disorders in New Mexico; defines covered indications, required ordering clinicians, and notes that WES/WGS are addressed in a separate policy.

Policy Summary

PayerUnitedHealthcare

PolicyGenetic Testing for Neurological Disorders (for New Mexico Only)

Policy CodePolicy CS165NM.C

Change TypeCoverage criteria revisedcodes removed

Effective DateJan 1, 2026

Next Review Date

Key ActionOrder multi-gene targeted panel (≥5 genes) only when clinical criteria are met and the test is ordered by or in consultation with a specified specialist.

SourceLink

POLICY UPDATE CHANGES

Revised language to indicate multi-gene Targeted Panel testing (five or more genes) for neurological disorders is proven and medically necessary when all specified criteria are met.

Added explicit requirement that the test be ordered by or in consultation with a medical geneticist, developmental pediatrician, or adult or pediatric neuromuscular or neurogenetics specialist.

Added statement that comprehensive panels intended to evaluate multiple genes across multiple clinically distinct neurological disorder categories are unproven and not medically necessary.

Removed CPT codes 0417U, 81440, 81460, and 81465.

5+minimum genes

NMstate

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covered condition count

Coverage Criteria

Targeted multi-gene panel coverage

Covered when ALL of the following are met

Eligibility for targeted multi-gene panel: 1) The individual to be tested displays signs or symptoms of a heritable neurological disorder and the results are expected to directly impact medical management of that disorder; 2) The test is ordered by or in consultation with a medical geneticist, developmental pediatrician, or adult or pediatric neuromuscular or neurogenetics specialist; 3) The test is intended to establish a genetic cause for any one of: Congenital or Metabolic Myopathy; Ataxia; Peripheral neuropathy; Hereditary spastic paraplegia; or Muscular dystrophy.

From Coverage Rationale (Multi-gene Targeted Panel testing, five or more genes)

Targeted multi-gene panel (covered conditions)

Covered when ALL of the following are met

Targeted panel coverage criteria: (1) The individual displays signs or symptoms of a heritable neurological disorder and results are expected to directly impact medical management; (2) The test is ordered by or in consultation with a medical geneticist, developmental pediatrician, or adult or pediatric neuromuscular or neurogenetics specialist; (3) The test is intended to establish a genetic cause for one of: congenital or metabolic myopathy, ataxia, peripheral neuropathy, or hereditary spastic paraplegia.panel includes five or more genes

Operationalized in Policy History/Revision Information

Comprehensive panels (not medically necessary)

Not covered when

Comprehensive panel not medically necessary: Comprehensive Panel tests intended to evaluate multiple genes associated with multiple categories of clinically distinct neurological disorders.

Considered unproven and not medically necessary due to insufficient evidence of efficacy (Clinical Evidence and Policy History).

Not Medically Necessary — Comprehensive Panels

Comprehensive panels: Comprehensive Panel tests intended to evaluate multiple genes associated with multiple categories of clinically distinct neurological disorders are unproven and not medically necessary due to insufficient evidence of efficacy.

From Policy History/Clinical Evidence.

Whole Exome Sequencing (WES) and Whole Genome Sequencing (WGS) are addressed in a separate Medical Policy and are not covered under this policy statement. See the Medical Policy titled Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) (for New Mexico Only) for coverage criteria for WES/WGS and how those tests relate to, and are distinguished from, multi-gene panel testing.

This policy is intended to support phenotype-directed testing using Targeted Panels (panels focused on genes associated with a specific clinical presentation). Current clinical evidence does not support routine use of broad or cross-category gene lists that include genes unrelated to the individual’s phenotype; such Comprehensive Panels lack demonstrated clinical utility compared with phenotype-directed targeted testing.

Comprehensive panels that evaluate genes across multiple clinically distinct neurological disorder categories are considered unproven and not medically necessary due to insufficient evidence of efficacy and therefore are not covered under this policy.

CPT/PLA codes 0417U, 81440, 81460, and 81465 have been removed from the policy’s Applicable Codes list and are no longer included as covered or supported codes in this policy.

Tests billed using CPT codes 0417U, 81440, 81460, and 81465 were removed from the Applicable Codes list in Policy History and are explicitly excluded from coverage under this policy.

Use of CPT codes 0417U, 81440, 81460, and 81465 has been removed from this policy; claims submitted using these removed codes may be denied or will not be processed for coverage under this policy.

Comprehensive panels that combine genes from multiple distinct neurological disorder categories (for example, mixing myopathy, ataxia, and peripheral neuropathy gene sets without a clear phenotype-directed rationale) are considered unproven and are not covered by this policy.

Comprehensive multi-category gene panels are not medically necessary and may be denied when submitted for members with signs or symptoms of heritable neurological disorders because current evidence does not demonstrate clinical utility for such broad panels.

Covered Indications

Establishing a genetic cause for congenital or metabolic myopathy, ataxia, peripheral neuropathy, or hereditary spastic paraplegia

Covered when ALL of the following are met

Panel requirement and ordering: 1) Test is a targeted multi-gene panel that includes five or more genes; 2) The individual displays signs or symptoms of a heritable neurological disorder with results expected to directly impact medical management; 3) The test is ordered by or in consultation with a medical geneticist, developmental pediatrician, or adult or pediatric neuromuscular or neurogenetics specialist; 4) The test is intended to establish a genetic cause for congenital or metabolic myopathy, ataxia, peripheral neuropathy, or hereditary spastic paraplegia.>= 5 genes

From Coverage Rationale and Policy History (panel gene count requirement).

Establishing a genetic cause for congenital or metabolic myopathy

Covered when ALL of the following are met

Establishing genetic cause — congenital or metabolic myopathy:

Applicable Codes and Coding Notes

Applicable procedure codes referencedCPT

0216U	Neurology (inherited ataxias), genomic DNA sequence analysis of 12 common genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants.
0217U	Neurology (inherited ataxias), genomic DNA sequence analysis of 51 genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants.
81448	Hereditary peripheral neuropathies (e.g., Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy-related genes (e.g., BSCL2 , GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1 ).
81479	Unlisted molecular pathology procedure

Applicable Codesmixed

No codes listed

Applicable Codesmixed

No codes listed

Removed CPT CodesCPTNot Covered

0417U	CPT code removed (0417U) per Policy History
81440	CPT code removed (81440) per Policy History
81460	CPT code removed (81460) per Policy History
81465	CPT code removed (81465) per Policy History

Removed CPT CodesCPTNot Covered

0417U	CPT code removed from policy
81440	CPT code removed from policy
81460	CPT code removed from policy
81465	CPT code removed from policy

Applicable Codes - RemovedCPTNot Covered

0417U	CPT code removed (0417U) as listed in Applicable Codes
81440	CPT code removed (81440) as listed in Applicable Codes
81460	CPT code removed (81460) as listed in Applicable Codes
81465	CPT code removed (81465) as listed in Applicable Codes

Removed CPT CodesCPTNot Covered

0417U	CPT code removed (0417U) per policy history
81440	CPT code removed (81440) per policy history
81460	CPT code removed (81460) per policy history
81465	CPT code removed (81465) per policy history

Removed CPT CodesCPTNot Covered

0417U	CPT code removed
81440	CPT code removed
81460	CPT code removed
81465	CPT code removed

Removed CPT CodesCPTNot Covered

0417U	CPT code removed
81440	CPT code removed
81460	CPT code removed
81465	CPT code removed

Removed CPT CodesCPTNot Covered

0417U	CPT code removed (as listed in Policy History/Applicable Codes)
81440	CPT code removed (as listed in Policy History/Applicable Codes)
81460	CPT code removed (as listed in Policy History/Applicable Codes)
81465	CPT code removed (as listed in Policy History/Applicable Codes)

Removed CPT CodesCPTNot Covered

0417U	CPT code 0417U (removed)
81440	CPT code 81440 (removed)
81460	CPT code 81460 (removed)
81465	CPT code 81465 (removed)

Applicable Codes — RemovedCPTNot Covered

0417U	CPT code removed
81440	CPT code removed
81460	CPT code removed
81465	CPT code removed

Removed CPT CodesCPTNot Covered

0417U	CPT code removed (document: Removed CPT codes 0417U...)
81440	CPT code removed (document: Removed CPT codes ... 81440...)
81460	CPT code removed (document: Removed CPT codes ... 81460...)
81465	CPT code removed (document: Removed CPT codes ... 81465...)

Panel gene count — minimum genes for a multi-gene targeted panel to be considered by this policy

Minimum panel sizePanels must include five or more genes (>=5 genes) to be considered under this policy

Rationale sourcePolicy applies to multi-gene targeted panels for neurological disorders as described in Coverage Rationale

Examples referencedPolicy references panels such as 12- and 51-gene inherited ataxia panels and peripheral neuropathy panels in coding examples

Provider Actions and Operational Notes

Prior Authorization

Verify Prior Authorization and Code Usage

Multi-gene targeted panel testing (≥5 genes) may require prior authorization. Verify current prior authorization requirements with the payer before ordering; policy history indicates updates and archival of prior versions, so check the current policy for any authorization references.

Verify whether prior authorization is required for the specific targeted panel prior to ordering
Check the current policy (do not rely on archived versions) for any prior authorization forms or code lists

Denial Risk

Specialist Ordering and Denial Risk for Comprehensive Panels

Targeted panel testing must be ordered by or in consultation with a medical geneticist, developmental pediatrician, or adult/pediatric neuromuscular or neurogenetics specialist. Comprehensive panels that span multiple clinically distinct neurological disorder categories are considered unproven and may be denied as not medically necessary.

Not Covered / Exclusions

NOT COVERED: Comprehensive panels that evaluate genes across multiple distinct neurological disorder categories are not covered under this policy; tests billed with removed CPT codes 0417U, 81440, 81460, and 81465 are also not covered.

NOT COVERED: Comprehensive panels spanning multiple clinically distinct neurological disorder categories are considered unproven and are not covered due to insufficient evidence of clinical benefit.

NOT COVERED: Comprehensive Panel tests intended to evaluate multiple genes associated with multiple categories of clinically distinct neurological disorders are unproven and not medically necessary.

NOT COVERED: Tests billed with CPT codes 0417U, 81440, 81460, or 81465 were removed from this policy and are not covered under removed-code entries; do not use these codes for coverage submissions.

NOT COVERED: CPT codes 0417U, 81440, 81460, and 81465 have been removed from the policy and are not covered under this policy segment.

NOT COVERED: Use of CPT codes 0417U, 81440, 81460, and 81465 is explicitly removed from this policy and therefore claims using these codes will not be accepted for coverage.

NOT COVERED: The removed CPT codes 0417U, 81440, 81460, and 81465 are no longer supported by this policy and should not be used for claim submission.

Definitions

Ataxia — definition

DefinitionAtaxia: A condition of the nervous system that causes loss of control of muscle movement and coordination.

Clinical noteAtaxia can be a symptom of another condition or occur as a primary disorder (NINDS, 2025).

Policy contextAtaxia is listed as a covered indication when testing is intended to establish a genetic cause under the targeted panel criteria.

Comprehensive Panel — definition

DefinitionComprehensive Panel: An assay that simultaneously tests more than one gene associated with a variety of conditions, symptoms, or non-overlapping clinical presentations.

Policy stanceComprehensive Panel tests that evaluate genes across multiple clinically distinct neurological disorder categories are considered unproven and not medically necessary.

Background and Evidence Summary

Background: Neurological disorders encompass neurodegenerative and neuromuscular conditions and other diseases of the brain, spinal cord, and peripheral nerves. Many have a genetic basis—over 500 genes are associated with neuromuscular disorders—and genetic testing options range from single-gene or single-variant testing to targeted multi-gene panels and broader Whole Exome Sequencing/Whole Genome Sequencing. Evidence supports a phenotype-directed approach: Targeted multi-gene panels (≥5 genes) aligned to the clinical presentation provide better diagnostic yield and clinical utility than broad, cross-category comprehensive panels that include genes unrelated to the phenotype.

Policy Summary

PayerUnitedHealthcare

PolicyGenetic Testing for Neurological Disorders (for New Mexico Only)

Policy CodePolicy CS165NM.C

Change TypeCoverage criteria revisedcodes removed

Effective DateJan 1, 2026

Next Review Date

Key ActionOrder multi-gene targeted panel (≥5 genes) only when clinical criteria are met and the test is ordered by or in consultation with a specified specialist.

SourceLink

On This Page

The individual displays signs or symptoms consistent with congenital or metabolic myopathy and results are expected to directly impact medical management; the test is ordered by or in consultation with a medical geneticist, developmental pediatrician, or adult or pediatric neuromuscular or neurogenetics specialist; the ordered test is a targeted multi-gene panel (five or more genes).

From Coverage Rationale.

Establishing a genetic cause for ataxia

Covered when ALL of the following are met

Establishing genetic cause — ataxia: The individual displays signs or symptoms consistent with ataxia and results are expected to directly impact medical management; the test is ordered by or in consultation with a medical geneticist, developmental pediatrician, or adult or pediatric neuromuscular or neurogenetics specialist; the ordered test is a targeted multi-gene panel (five or more genes).

From Coverage Rationale.

Establishing a genetic cause for peripheral neuropathy

Covered when ALL of the following are met

Establishing genetic cause — peripheral neuropathy: The individual displays signs or symptoms consistent with peripheral neuropathy and results are expected to directly impact medical management; the test is ordered by or in consultation with a medical geneticist, developmental pediatrician, or adult or pediatric neuromuscular or neurogenetics specialist; the ordered test is a targeted multi-gene panel (five or more genes).

From Coverage Rationale.

Establishing a genetic cause for hereditary spastic paraplegia

Covered when ALL of the following are met

Establishing genetic cause — hereditary spastic paraplegia: The individual displays signs or symptoms consistent with hereditary spastic paraplegia and results are expected to directly impact medical management; the test is ordered by or in consultation with a medical geneticist, developmental pediatrician, or adult or pediatric neuromuscular or neurogenetics specialist; the ordered test is a targeted multi-gene panel (five or more genes).

From Coverage Rationale.

Establishing a genetic cause for muscular dystrophy

Covered when ALL of the following are met

Establishing genetic cause — muscular dystrophy: The individual displays signs or symptoms consistent with muscular dystrophy and results are expected to directly impact medical management; the test is ordered by or in consultation with a medical geneticist, developmental pediatrician, or adult or pediatric neuromuscular or neurogenetics specialist; the ordered test is a targeted multi-gene panel (five or more genes).

From Coverage Rationale.

Order/consult requirement: medical geneticist, developmental pediatrician, or neuromuscular/neurogenetics specialist
Denial risk: Comprehensive panels intended to evaluate genes across multiple distinct neurological disorder categories are not medically necessary and may be denied

Billing Rule

Removed CPT Codes — Verify Authorization and Billing Codes

The policy history documents removal of CPT codes 0417U, 81440, 81460, and 81465. Providers must not submit prior authorization requests or claims using these removed codes; continued use may result in claim denials or processing failures.

Do not use removed CPT codes 0417U, 81440, 81460, 81465 for authorization requests or billing
Verify the payer's current acceptable CPT/HCPCS codes before submission to avoid denial

Documentation Required

Documentation Requirements and Updated Expectations

Medical record documentation may be required to assess whether the member meets clinical criteria. The patient’s medical record must fully support medical necessity — including relevant history, physical exam, and diagnostic test results — and must be made available upon request. Updated Description of Services and Clinical Evidence in the policy may change documentation expectations.

Documentation must include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures
Ensure documentation reflects the current Description of Services and Clinical Evidence cited in the policy
Providing documentation does not guarantee coverage; incomplete records may lead to denial

Denial Risk

Operational and Coding Risks — Documentation and Removed Codes

Operational notes: medical records may be requested during review, and insufficient or inconsistent coding relative to the current policy may trigger claim processing issues or denials. Verify that authorization references do not include removed codes and that supporting documentation aligns with the revised policy.

Medical records may be required to confirm clinical criteria; submission of records does not guarantee approval
Confirm that any prior authorization submission does not reference removed CPT codes
Inadequate documentation or use of removed codes increases the risk of denial

NOT COVERED: Claims using CPT codes 0417U, 81440, 81460, or 81465 may be denied because these codes were removed from the policy’s Applicable Codes list.

NOT COVERED: Testing represented by CPT codes 0417U, 81440, 81460, and 81465 is no longer covered under this policy section following removal from the Applicable Codes list.

NOT COVERED: Removed CPT codes 0417U, 81440, 81460, and 81465 should not be used for coverage or claim submission; they were removed from the policy’s Applicable Codes.

NOT COVERED: Tests billed under CPT codes 0417U, 81440, 81460, or 81465 are no longer listed in the Applicable Codes and are not covered by this policy.

NOT COVERED: Tests billed using removed CPT codes 0417U, 81440, 81460, and 81465 are not listed as applicable and are not covered under this policy segment.

NOT COVERED: Tests billed with CPT codes 0417U, 81440, 81460, or 81465 (codes removed from the policy) are not covered under this policy segment.

ImplicationComprehensive panels are not covered under this policy due to insufficient evidence of efficacy; WES/WGS addressed in separate policy.

Targeted Panel — definition

DefinitionTargeted Panel: A curated assay that simultaneously tests more than one gene associated with a condition or related symptom set.

GuidanceInitial testing should be guided by clinical phenotype and focus on the most common relevant genes where appropriate.

ContrastTargeted panels differ from comprehensive panels by focusing on phenotype-directed gene sets rather than multiple distinct disorder categories.

Whole Exome Sequencing (WES) — definition

DefinitionWhole Exome Sequencing (WES): DNA analysis that looks at all exons (protein-coding regions) in a person's genome at one time rather than gene by gene.

ScopeWES examines the exome (approximately 1% of the genome representing protein-coding regions).

Policy noteWES and WGS are addressed in a separate Medical Policy (Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions)).

Whole Genome Sequencing (WGS) — definition

DefinitionWhole Genome Sequencing (WGS): Determines the sequence of all nucleotides in a person's entire DNA, including coding and non-coding regions.

ScopeWGS analyzes both protein-coding (coding) and non-coding DNA elements across the whole genome.

Policy noteWES and WGS are addressed in a separate Medical Policy and are not covered under this targeted-panel policy statement.

Targeted multi-gene panel — NGS assay focused on curated gene set

DefinitionTargeted multi-gene panel: A next-generation sequencing (NGS) assay focused on a curated set of genes associated with a specific phenotype or neurologic disorder category (e.g., myopathy, neuropathy, ataxia).

MethodologyTypically performed using NGS methods to analyze multiple genes simultaneously in a phenotype-directed gene set.

Intended useUsed to establish a genetic cause for a specific heritable neurological disorder when results are expected to impact medical management.

CLIA-regulated laboratory — definition / regulatory note

DefinitionCLIA-regulated laboratory: Laboratories that perform genetic tests are regulated under the Clinical Laboratory Improvement Amendments (CLIA) Act of 1988.

Regulatory noteFDA informational resources for nucleic acid-based tests/platforms are provided for informational purposes; FDA approval alone is not a basis for coverage.

Reference linkPolicy cites FDA pages listing cleared/approved nucleic acid-based tests (accessed May 16, 2025).

Ataxia (definition added in policy history)

Definition addedAtaxia: definition added to policy history as 'loss of control of muscle movement and coordination.'

ContextPolicy History notes definitions were added (Ataxia among others) and documentation requirements emphasized.

ImplicationAdded definitions clarify covered indications for targeted panel testing in revision history.

Comprehensive Panel (definition added in policy history)

Definition addedComprehensive Panel: definition added in policy history; an assay testing multiple genes across multiple clinically distinct neurological disorder categories.

Policy impactPolicy history explicitly states comprehensive panels of this type are unproven and not medically necessary.

DocumentationThe addition of this definition coincides with revision language on coverage and not medically necessary stance for comprehensive panels.

Congenital Myopathy (definition added)

Definition addedCongenital Myopathy: Abnormality affecting muscle development, typically manifesting at birth or early infancy (examples: central core disease, centronuclear myopathy, nemaline myopathy).

Clinical featuresMay present with muscle weakness, hypotonia, and respiratory distress.

Policy relevanceListed as a covered indication when targeted multi-gene panel testing is intended to establish a genetic cause.

Metabolic Myopathy (definition added)

Definition addedMetabolic Myopathy: Abnormality from inborn errors of metabolism (e.g., glycogen storage diseases, fatty acid metabolism defects) causing muscle symptoms such as cramps, exercise intolerance, and progressive weakness.

Clinical featuresSymptoms may include exercise intolerance and progressive weakness in trunk and extremities.

Policy relevanceIncluded among covered indications for targeted multi-gene panel testing when genetic cause impacts management.

Targeted Panel (definition added)

Definition addedTargeted Panel: definition reiterated/added in policy history as a curated assay testing multiple genes associated with a condition.

ClarificationPolicy history entries note Targeted Panel as a distinct concept from comprehensive multi-category panels.

ImplicationTargeted Panel definitions support the policy's coverage of phenotype-directed multi-gene panels (>=5 genes).

Variant of Unknown Significance (VUS) — definition added

Definition addedVariant of Unknown Significance (VUS): VUS was added to the definitions in policy history.

ContextPolicy history includes NGS and VUS additions to definitions and Applicable Codes entries.

ImplicationRecognition of VUS in definitions reflects policy updates addressing NGS-based testing results handling (details limited in these chunks).

Policy content updates — Description of Services, Clinical Evidence, FDA updated in policy history

Sections updatedDescription of Services, Clinical Evidence, and FDA sections were updated as noted in Policy History/Revision Information.

Supporting infoMultiple policy history entries reference updates to supporting information and Description of Services.

Implication for providersProviders should reference the revised Description of Services and Clinical Evidence when preparing documentation for coverage reviews.