Q79.61 — Classical Ehlers-Danlos syndrome
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Test panel must include at minimum the COL5A1 and COL5A2 genes.
- Clinical evaluation findings and family history documenting features consistent with hEDS (since hEDS diagnosis is clinical and genetic testing is not appropriate for hEDS).
- Refer to policy section for documentation required when evaluating non-hEDS EDS subtypes (if pursuing genetic evaluation for other EDS types).
- Submission of the pertinent ICD-10-CM diagnosis code(s) supporting testing (examples: I71.00-I71.9 for TAAD; Q87.5 for Loeys‑Dietz; M35.7, Q79.61, Q79.63, Q79.69 for Ehlers‑Danlos).
Key Coverage Criteria
- Myopathic EDS with clinical features suggestive of the disorder (COL12A1).
- Periodontal EDS with clinical features suggestive of the disorder (C1R, C1S).
- Spondylodysplastic EDS with clinical features suggestive of the disorder (B4GALT7, B3GALT6, SLC39A13).
- Genetic testing for hereditary connective tissue disorders when clinical features suggest a HCTD (e.g., generalized joint hypermobility, thoracic aortic aneurysm or dissection).
- Genetic testing when results are expected to change clinical management, such as initiation or modification of aortic surveillance, surgical planning for the aorta, or multisystem surveillance for syndromic conditions with risk of thoracic aortic aneurysm/dissection.
- Genetic testing when clinical and family history alone are insufficient to reliably establish a diagnosis of a hereditary connective tissue disorder.
2 Active Policies
AMBETTER-CG-Aorto-2025.1 — Concert Genetic Testing: Aortopathies and Connective Tissue Disorders
AMBETTER-CP.MP.99 — Wheelchair Seating
Related Codes
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