0456U
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of patient age to confirm adult status (≥18 years).
- Clinical documentation that the member initiated a biologic or targeted synthetic DMARD for RA and is unresponsive/refractory or intolerant despite therapeutic dosing.
- Documentation confirming no prior molecular biomarker testing for predictive therapy selection for rheumatoid arthritis.
- Clinical or radiographic documentation supporting the diagnosis or suspicion of axial spondyloarthritis when ordering HLA-B27 typing.
Key Coverage Criteria
- Genetic testing for inherited immunodeficiency disorders
- Molecular biomarker testing to predict response or non-response to medications for rheumatoid arthritis and related autoimmune disorders
- Multigene panels for suspected Periodic Fever Syndromes (e.g., tests such as Invitae or PreventionGenetics) for members with clinical features consistent with periodic fever (ICD-10: M04.1, R50.9, A68.9).
- Rheumatoid arthritis biomarker activity panels (e.g., Vectra) for assessment of disease activity in members with diagnosed rheumatoid arthritis (ICD-10: M05.00-M06.9).
- TNF inhibitor (TNFi) treatment response algorithmic tests (e.g., PrismRA) to inform expected response to TNFi therapy in members with rheumatoid arthritis (ICD-10: M05, M06, M08).
- HLA-B27 DNA typing for evaluation of axial spondyloarthritis or related seronegative spondyloarthropathies (ICD-10: M45 and related codes such as M04.8, M04.9, M05, M06).
1 Active Policy
AMBETTER-CG-Immune.Auto.RA.DO-2025.1 — Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders
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