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    v1.0.28
    OpenPayerPolicy UpdatesGenetic & Molecular TestingUniversity of Utah PGx Policy Update | OpenPayer
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    CurrentUniversity of Utah Health PlansPolicy MP-030

    Pharmacogenomic Testing for Behavioral Health Disorders

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    This policy governs coverage of genetic and pharmacogenomic testing used to diagnose, predict, or guide medication selection and dosing for behavioral health disorders. It applies to commercial, CHIP, Healthy U Medicaid, and Health Choice Utah Medicaid plans; Medicaid coverage is subject to Utah Medicaid policy and applicable criteria.

    Policy Summary
    PayerUniversity of Utah Health Plans
    PolicyPharmacogenomic Testing for Behavioral Health Disorders
    Policy CodePolicy MP-030
    Change TypeNo material clinical or coverage changes
    Effective DateOct 15, 2025
    Last ReviewOct 15, 2025
    Next Review DateOct 15, 2026
    Key ActionConfirm that the requested service is a covered benefit under the member’s plan and that the member is eligible for coverage on the date of service.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Not coveredCommercial/CHIP coverage stance
    23Named behavioral-health tests or panels listed as investigational

    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.

    31Non-covered molecular pathology and pharmacogenomic codes
    Medicaid-specificMedicaid coverage pathway
    3Excluded commercial/CHIP testing purposes

    Behavioral-Health Genetic Testing Coverage

    Commercial Plans/CHIP Behavioral-Health Genetic Testing

    Commercial plans and CHIP do not cover behavioral-health genetic testing because it is considered investigational in all situations.

    ALL of the following apply

    • The requested testing is genetic testing for the diagnosis or management of a behavioral-health disorder.
    • The testing is requested to confirm a behavioral-health diagnosis in an individual with symptoms; predict future risk of a behavioral-health disorder in an asymptomatic individual; or inform the selection or dose of medications used to treat behavioral-health disorders.

    Examples include AIBioTech® CardioloGene or PsychiaGene Genetic Panels, Pain Management, PersonaGene or Urologene Panels; Genecept Assay Genomind®; GeneSight MTHFR; GeneSight® Analgesic, ADHD, or Psychotropic panels; GENETWORx Neuropsychiatric Panel; IDgenetix-branded tests; INFINITI Neural Response Panel; Mental Health DNA Insight panel; Millennium PGT SM; MindX One™ Blood Test; MyGenVar Pharmacogenomics Test; OneOme RightMed Pharmacogenomic Test; Proove® Opioid Risk assay or Drug Metabolism test panel; Psych HealthPGx Panel by RPRD Diagnostics; RightMed Mental Health Gene Report; RightMed Mental Health Medication Report; and SureGene Test for Antipsychotic and Antidepressant Response STA 2 R test.

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    Non-Covered Procedure Codes

    Non-Covered CodesCPTNot Covered
    0029UDrug metabolism (adverse drug reactions and drug response), targeted sequence analysis (i.e., CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs12777823)
    0032UCOMT (catechol-O-methyltransferase) (drug metabolism) gene analysis, c.472G>A (rs4680) variant
    0033UHTR2A (5-hydroxytryptamine receptor 2A), HTR2C (5-hydroxytryptamine receptor 2C) (e.g., citalopram metabolism) gene analysis, common variants (i.e., HTR2A rs7997012 [c.614-2211T>C], HTR2C rs3813929 [c.-759C>T] and rs1414334 [c.551-3008C>G])
    0070UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, common and select rare variants (ie, *2, *3, *4, *4N, *57, *61, *63, *68, *83, *xN)
    0071UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, full gene sequence (List separately in addition to code for primary procedure)
    0072UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D6-2D7 hybrid gene) (List separately in addition to code for primary procedure)
    0073UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D7-2D6 hybrid gene) (List separately in addition to code for primary procedure)
    0074UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, non-duplicated gene when duplication/multiplication is trans) (List separately in addition to code for primary procedure)
    0075UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 5' gene duplication/multiplication) (List separately in addition to code for primary procedure)
    0076UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 3' gene duplication/multiplication) (List separately in addition to code for primary procedure)
    1–10 of 28
    1/3
    Non-Covered CodesCPTNot Covered
    0076UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 3' gene duplication/multiplication) (List separately in addition to code for primary procedure)
    0173UPsychiatry (eg, depression, anxiety), genomic analysis panel, variant analysis of 14 genes
    0175UPsychiatry (eg, depression, anxiety), genomic analysis panel, variant analysis of 15 genes
    0291UPsychiatry (mood disorders), mRNA, gene expression profiling by RNA sequencing of 144 genes, whole blood, algorithm reported as predictive risk score
    0292UPsychiatry (stress disorders), mRNA, gene expression profiling by RNA sequencing of 72 genes, whole blood, algorithm reported as predictive risk score
    0293UPsychiatry (suicidal ideation), mRNA, gene expression profiling by RNA sequencing of 54 genes, whole blood, algorithm reported as predictive risk score
    0345UPsychiatry (eg, 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
    0350UDrug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes
    1–10 of 25
    1/3

    Authorization, Verification, and Billing Actions

    Prior Authorization

    Obtain Required Prior Authorization

    Obtain prior authorization before providing services that require it. Services requiring prior authorization may not be covered when authorization has not been obtained.

    Documentation Required

    Verify Benefits and Eligibility

    Before rendering the service, confirm that it is a covered benefit under the member’s plan and verify that the member is eligible for coverage on the date of service. This policy does not guarantee coverage or payment.

    Note

    Verify Medicaid Coverage and Criteria

    For Medicaid members, verify the current Utah Medicaid coverage position and applicable medical-necessity criteria. If Utah Medicaid has no published coverage position and InterQual criteria are unavailable, the U of U Health Plans Commercial criteria apply; Medicaid-covered CPT/HCPCS codes may still require further evaluation.

    Pharmacogenomic Testing Overview

    Pharmacogenomic testing evaluates inherited genetic variation that may affect drug metabolism, transport, receptors, or signaling pathways. The testing has been proposed to predict medication response or adverse effects and to guide selection or dosing of psychotropic medications. The policy identifies the supporting evidence as insufficient, inconsistent, and generally low quality for demonstrating improved clinical outcomes or clinical utility; accordingly, commercial and CHIP coverage considers this testing investigational in all situations.

    Key Pharmacogenomic Terms

    Definitions
    Pharmacogenomic studyTesting of an individual's genetic inheritance to evaluate how genetic variation may affect the body's response to drugs, including drug metabolism, receptors, transporters, and signal-transduction pathways.
    Definitions
    Germline pharmacogenomic variationInherited DNA sequence variation in genes related to a drug's metabolic pathway (pharmacokinetics) or signal-transduction pathway (pharmacodynamics).
    Definitions
    Complex pharmacogenetic traitA multifactorial quantitative trait influenced by numerous small-effect variants together with epigenetic and environmental factors.

    Explicitly Excluded Services

    For commercial and CHIP plans, genetic testing and genetic testing panels used to diagnose, predict, or manage behavioral-health disorders are not covered. This includes testing intended to confirm a diagnosis, predict future risk, or guide psychotropic medication selection or dosing.

    The policy explicitly identifies named behavioral-health pharmacogenomic tests and panels as investigational and not covered, including AIBioTech CardioloGene, PsychiaGene, Pain Management, PersonaGene, and Urologene panels; Genecept Assay/Genomind; GeneSight MTHFR, Analgesic, ADHD, and Psychotropic panels; GENETWORx Neuropsychiatric Panel; IDgenetix-branded tests; INFINITI Neural Response Panel; Mental Health DNA Insight; Millennium PGT SM; MindX One Blood Test; MyGenVar Pharmacogenomics Test; OneOme RightMed; Proove Opioid Risk and Drug Metabolism panels; Psych HealthPGx; RightMed Mental Health reports; and the SureGene STA 2 R test.

    The non-covered category includes psychiatric genomic analysis panels, psychiatric mRNA gene-expression profiling, pharmacogenomic drug-metabolism panels, individual CYP and MTHFR gene analyses, molecular pathology level 2 procedures, and unlisted molecular pathology procedures. The listed services include panels analyzing 14 to 27 genes, predictive-risk gene-expression tests, and testing involving CYP2C19, CYP2D6, CYP3A4, CYP3A5, or MTHFR.

    Policy Summary
    PayerUniversity of Utah Health Plans
    PolicyPharmacogenomic Testing for Behavioral Health Disorders
    Policy CodePolicy MP-030
    Change TypeNo material clinical or coverage changes
    Effective DateOct 15, 2025
    Last ReviewOct 15, 2025
    Next Review DateOct 15, 2026
    Key ActionConfirm that the requested service is a covered benefit under the member’s plan and that the member is eligible for coverage on the date of service.
    SourceLink
    On This Page
    Behavioral-Health Genetic Testing CoverageNon-Covered Procedure CodesAuthorization, Verification, and Billing ActionsPharmacogenomic Testing OverviewKey Pharmacogenomic TermsExplicitly Excluded Services
    • Check current Utah Medicaid policies and coverage at https://medicaid.utah.gov/utah-medicaidofficial-publications/ or through the Utah Medicaid code Look-Up tool.
    • Coverage is determined by the State of Utah Medicaid program.
    Denial Risk

    Missing Prior Authorization

    Do not perform or bill a service requiring prior authorization until the authorization has been obtained. Claims may be denied when required authorization is missing.

    Denial Risk

    Investigational Behavioral-Health Genetic Testing

    Commercial and CHIP plans do not cover genetic testing for the diagnosis or management of behavioral health disorders because it is considered investigational in all situations and indications.

    • This includes testing to confirm a diagnosis, predict future risk in an asymptomatic individual, or inform selection or dosing of behavioral-health medications.
    • Examples include testing related to selective serotonin reuptake inhibitors, selective norepinephrine or serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and antipsychotic drugs.
    • Non-covered branded panels and assays include AIBioTech CardioloGene or PsychiaGene, Genecept/Genomind, GeneSight MTHFR and Analgesic/ADHD/Psychotropic panels, GENETWORx Neuropsychiatric Panel, IDgenetix, INFINITI Neural Response Panel, Mental Health DNA Insight, Millennium PGT, MindX One, MyGenVar, OneOme RightMed, Proove Opioid Risk or Drug Metabolism, Psych HealthPGx, RightMed Mental Health reports, and SureGene STA 2 R.
    Billing Rule

    Non-Covered Procedure Codes

    Do not submit the following pharmacogenomic, drug-metabolism, psychiatry genomic-panel, gene-expression, or related molecular pathology procedure codes for coverage under this policy; they are non-covered.

    • 0173U, 0175U, 0291U, 0292U, 0293U, 0345U, 0347U, 0348U, 0350U, 0392U, 0411U, 0419U, 0423U, 0437U, 0476U, and 0477U
    • 81225, 81226, 81230, 81231, 81291, 81401, 81418, and 81479
    Denial Risk

    Non-Covered Pharmacogenomic and Molecular Testing Codes

    Claims for the listed pharmacogenomic, psychiatric genomic, gene-expression, drug-metabolism, or molecular pathology services are non-covered. Review code selection before billing and do not substitute an unlisted or related molecular code to seek coverage.

    • Pharmacogenomic and drug-metabolism codes: 0076U, 81225, 81226, 81230, 81231, 81418
    • Psychiatric genomic-panel and neuropsychiatric codes: 0173U, 0175U, 0345U, 0411U, 0419U, 0423U, 0476U, 0477U
    • Psychiatric gene-expression codes: 0291U, 0292U, 0293U, and 0437U
    • Drug-metabolism, gene-drug interaction, and molecular pathology codes: 0347U, 0348U, 0350U, 0392U, 81401, and 81479