E34.52 — Partial androgen insensitivity syndrome
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Rigorous clinical evaluation should precede diagnostic molecular testing.
- Disease-specific diagnostic criteria or clinical findings as listed throughout the policy must be documented (e.g., Amsterdam II or revised Bethesda for Lynch syndrome; Schwartz score for LQTS; clinical criteria for Marfan Syndrome [see Appendix]; clinical features lists for Angelman, Prader-Willi, CADASIL, etc.).
- For general medical necessity: documentation that all of the following are met: The member displays clinical features, or is at direct risk of inheriting the mutation (pre-symptomatic); and The result of the test will directly impact the treatment being delivered to the member; and After history, physical examination, pedigree analysis, genetic counseling, and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a suspected diagnosis is listed; and Disease-specific criteria met.
Key Coverage Criteria
- Loeys-Dietz syndrome (TGFBR1, TGFBR2): Testing medically necessary when: asymptomatic individual has affected first-degree relative with known deleterious mutation (test for familial mutation); or to confirm diagnosis in individual with LDS characteristics (begin with TGFBR2 sequencing, then TGFBR1 if negative).
- I42.0 Dilated cardiomyopathy [hereditary]
- I49.01 Ventricular fibrillation
- I71.01 Dissection of thoracic aorta
- Von Hippel-Lindau syndrome (VHL)
- Walker-Warburg syndrome (POMGNT1)
2 Active Policies
AETNA-CPB-0140 — Genetic Testing
ANTHEM-CG-SURG-88 — CG-SURG-88 Mastectomy for Gynecomastia
Related Codes
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