81356
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation confirming diagnosis of infantile-onset inflammatory bowel disease with documented age of onset before 2 years.
- Document clinical evidence of infection susceptibility (type/frequency of infections) when claimed.
- Clinical documentation that the member is being evaluated for celiac disease.
- Documentation of an inconclusive serology (antibody) result or an inconclusive histology (biopsy) result, or documentation that the member started a gluten-free diet prior to evaluation.
Key Coverage Criteria
- Genetic testing to confirm diagnosis in patients with signs and/or symptoms of a specific non-cancerous gastroenterologic disorder (e.g., celiac disease, Crohn's disease, hereditary hemochromatosis) when confirmation may alter management or obviate further diagnostic workup.
- HLA-DQ genotyping (HLA typing) for evaluation/assessment of celiac disease susceptibility or diagnosis.
- HFE C282Y and H63D genotyping for evaluation of suspected hereditary hemochromatosis.
- Multigene panel testing for hereditary pancreatitis to detect pathogenic variants associated with hereditary pancreatitis.
- Prometheus IBD diagnostic algorithmic testing for evaluation/diagnosis of inflammatory bowel disease/Crohn's disease.
- Prometheus Crohn's prognostic algorithmic testing for prognostic assessment in Crohn's disease.
1 Active Policy
AMBETTER-CG-Gastro-Disorders-NonCa-2025.1 — Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous)
Related Codes
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