0380U — Rx metb advrs trgt sq aly 20
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claim must be accompanied by an appropriate ICD-10-CM diagnosis code(s) that supports medical necessity (see codes listed in the policy table).
- Clinical documentation demonstrating that test results will inform medication selection or dosing (e.g., relevant medication history, reason for testing) — specific required documents not listed in excerpt.
- Claims must include an appropriate ICD-10-CM diagnosis code from the policy’s listed codes to justify testing.
- Medical record documentation must support the clinical rationale for pharmacogenetic testing (i.e., documentation that test results will be used to guide medication selection or dosing).
Key Coverage Criteria
- Pharmacogenetic testing prior to drug initiation to identify germline variants that may alter drug response or increase risk of drug toxicity.
- Pharmacogenetic testing during treatment to evaluate an adverse drug reaction or to assess therapeutic response and guide ongoing medication management.
- Pharmacogenetic panel testing (examples: GeneSight, Genomind, Neuropharmagen, NeuroIDgenetix, Tempus nP, IDgenetix, PersonalisedRX, PGXPSYCH, Focused Pharm Panel) to inform psychotropic medication selection or management in patients with psychiatric disorders or related conditions.
- Pharmacogenetic panel testing to guide medication selection or dosing for patients with oncologic, neurologic, cardiovascular, vascular, thrombotic, or gastrointestinal conditions when gene–drug interactions may affect therapy (see associated ICD-10-CM codes).
- Single-gene pharmacogenetic testing (examples: BCHE, CYP2C9, CYP2C19) when the test result will directly inform drug therapy decisions or dosing for an individual patient.
- CYP2D6 pharmacogenetic testing (e.g., Variant Analysis 81226 and related PLA/unique codes 0070U–0076U) when used to guide medication selection or dosing for a patient who has one of the ICD-10-CM diagnoses listed in the policy.
1 Active Policy
AMBETTER-CG-Pharmacogenetics-2025.1-Version-B — Concert Genetic Testing: Pharmacogenetics (Version B)
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.