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    v1.0.28
    OpenPayerPolicy UpdatesGenetic & Molecular TestingUnitedHealthcare PGx Coverage Update | OpenPayer
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    ModifiedUnitedHealthcarePolicy CS149NM.H

    Pharmacogenetic Panel Testing (for New Mexico Only)

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    This policy governs coverage of pharmacogenetic multigene panels and the PrismRA molecular signature test for UnitedHealthcare Community Plan members in New Mexico, including testing for drug-metabolizer status and prediction of response to anti-TNF therapy in rheumatoid arthritis.

    Policy Summary
    PayerUnitedHealthcare
    PolicyPharmacogenetic Panel Testing (for New Mexico Only)
    Policy CodePolicy CS149NM.H
    Change TypeModified
    Effective DateOctober 1, 2026
    Next Review DateNot specified
    Key ActionDo not submit claims for pharmacogenetic multigene panels testing five or more genes for drug-metabolizer status, as they are subject to denial.
    SourceLink
    POLICY UPDATE CHANGES

    The list of applicable CPT codes was updated to reflect quarterly edits.

    CPT code 0697U was added to the applicable code list.

    The clinical evidence and references sections were updated with current information.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    5+ genes
    Multigene panel threshold
    2Testing categories designated not medically necessary
    21Applicable procedure and molecular pathology codes
    New MexicoState-specific application
    1New applicable CPT code

    Coverage Criteria

    Pharmacogenetic Multigene Panels

    Not medically necessary for any indication.

    Pharmacogenetic multigene panels: Use of pharmacogenetic multigene panels for the evaluation of drug-metabolizer status is unproven and not medically necessary for any indication.Five or more genes

    Due to insufficient evidence of efficacy.

    PrismRA Molecular Signature Test

    Not medically necessary for the specified indication.

    PrismRA molecular signature test: Use of the PrismRA molecular signature test is unproven and not medically necessary for evaluating the likelihood of inadequate response to anti-TNF therapies for rheumatoid arthritis.

    Due to insufficient evidence of efficacy.

    Routine use of pharmacogenetic (PGx) panel testing to assess risk related to chemotherapy-induced cardiotoxicity is not supported at this time. Although preliminary research suggests potential benefit, additional prospective studies with long-term follow-up are needed to validate its clinical role.

    Use of multigene PGx testing in pain management to predict treatment response, side effects, or dependence, or to improve overall treatment outcomes, is not currently supported as safe or efficacious in the peer-reviewed literature.

    Pharmacogenetic multigene panels testing five or more genes to evaluate drug-metabolizer status are unproven and not medically necessary for any indication because evidence of efficacy is insufficient.

    The PrismRA molecular signature test used to evaluate the likelihood of inadequate response to anti-TNF therapies for rheumatoid arthritis is unproven and not medically necessary because evidence of efficacy is insufficient.

    Use of pharmacogenetic multigene panel testing to guide individualized therapy for multimorbidity, polypharmacy, cancer treatment toxicity, medication response, inflammatory bowel disease, or general medication prescribing is not supported by sufficient evidence. Clinical efficacy has not been substantiated in the scientific literature.

    Applicable Codes and Coding Parameters

    Applicable CodesCPT
    0173UPsychiatry (i.e., depression, anxiety), genomic analysis panel, includes variant analysis of 14 genes.
    0175UPsychiatry (e.g., depression, anxiety), genomic analysis panel, variant analysis of 15 genes
    0345UPsychiatry (e.g., depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6.
    0347UDrug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 16 gene report, with variant analysis and reported phenotypes.
    0348UDrug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 25 gene report, with variant analysis and reported phenotypes.
    0349UDrug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis, including reported phenotypes and impacted gene-drug interactions.
    0350UDrug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication analysis of CYP2D6, reported as impact of gene-drug interaction for each drug.
    0411UPsychiatry (e.g., depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6.
    0419UNeuropsychiatry (e.g., depression, anxiety), genomic sequence analysis panel, variant analysis of 13 genes, saliva or buccal swab, report of each gene phenotype.
    0434UDrug metabolism (adverse drug reactions and drug response), genomic analysis panel, variant analysis of 25 genes with reported phenotypes.
    1–10 of 21
    1/3
    Applicable CPT CodesCPT
    0697UApplicable CPT code added to the list; the specific code description is not provided in this window.
    Multigene Panel Size
    ThresholdFive or more genes
    Testing categoryPharmacogenetic Multigene Panel
    Primary use addressedProactively evaluating an individual's possible response to many drugs, including drug-metabolizer status

    Provider and Billing Actions

    Denial Risk

    Multigene Pharmacogenetic Panels

    Claims for pharmacogenetic multigene panels testing five or more genes to evaluate drug-metabolizer status are subject to denial because the service is considered unproven and not medically necessary for any indication.

    Denial Risk

    PrismRA® Molecular Signature Test

    Claims for the PrismRA® molecular signature test used to evaluate the likelihood of inadequate response to anti-TNF therapies for rheumatoid arthritis are subject to the policy limitation because the test is considered unproven and not medically necessary.

    Denial Risk

    Anthracycline Cardiotoxicity Testing

    Routine pharmacogenetic panel testing to assess risk of chemotherapy-induced cardiotoxicity (CIC) is not supported by the available evidence. Initial research is promising, but additional prospective studies with long-term follow-up are needed to validate the role of pharmacogenetics in CIC.

    Background

    Pharmacogenetics, also called pharmacogenomics, evaluates how genetic variation may affect an individual's response to medications, including treatment benefit and adverse effects. Targeted testing for a specific drug commonly analyzes one gene, whereas this policy addresses multigene panels that proactively evaluate possible responses to multiple drugs. The policy also addresses PrismRA, a molecular signature test intended to evaluate inadequate response to anti-TNF therapy in rheumatoid arthritis.

    Definitions

    Multigene Panel
    DefinitionGenetic tests that typically use next-generation sequencing to test multiple genes simultaneously
    Alternate termMultigene test
    Alternate termMultiple-gene panel test
    Alternate termMultiple-gene test

    Not Covered Services

    The following services are not covered under this policy: pharmacogenetic multigene panels used to evaluate drug-metabolizer status for any indication; the PrismRA molecular signature test used to evaluate the likelihood of inadequate response to anti-TNF therapies for rheumatoid arthritis; routine multigene PGx testing for anthracycline-related chemotherapy-induced cardiotoxicity; multigene PGx testing for pain-treatment response, adverse effects, dependence, or overall treatment outcomes; and multigene PGx testing intended to guide individualized therapy for multimorbidity, polypharmacy, cancer treatment toxicity, medication response, inflammatory bowel disease, or general medication prescribing.

    Policy Summary
    PayerUnitedHealthcare
    PolicyPharmacogenetic Panel Testing (for New Mexico Only)
    Policy CodePolicy CS149NM.H
    Change TypeModified
    Effective DateOctober 1, 2026
    Next Review DateNot specified
    Key ActionDo not submit claims for pharmacogenetic multigene panels testing five or more genes for drug-metabolizer status, as they are subject to denial.
    SourceLink
    On This Page
    Coverage CriteriaApplicable Codes and Coding ParametersProvider and Billing ActionsBackgroundDefinitionsNot Covered Services
    • Do not assume routine multigene PGx panel testing for anthracycline-related cardiotoxicity is supported for coverage.
    • The evidence base requires further prospective validation and long-term follow-up.
    Denial Risk

    Pain-Management PGx Testing

    Multigene pharmacogenetic testing for pain management is not currently supported as safe or efficacious for predicting treatment response, side effects, or dependence, or for improving overall treatment outcomes.

    Note

    FDA Status Alone Does Not Establish Coverage

    FDA approval or clearance alone does not establish coverage. Coverage remains subject to the policy's medical-necessity and coverage requirements.