S3853, Genetic testing for myotonic muscular dystrophy
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Providers must reference and use the most up-to-date CPT manuals and professional coding guidance prior to claim submission.
- Refer to the Concert Platform for the comprehensive list of registered tests and any required documentation for coverage decisions.
- Clinical documentation that supports the specific ICD-10 diagnosis associated with the requested genetic test (use the ICD-10 codes shown for each test).
- Medical record documentation of relevant signs/symptoms and/or family history indicating the need for the specific gene or panel testing.
Key Coverage Criteria
- Elevated serum creatine kinase (CK) levels
- Member must meet at least one of the additional criteria in section B (section B not included in this fragment)
- Same genetic testing when there is progression of weakness after pregnancy.
- Same genetic testing when there is a prior diagnosis of inflammatory myopathy that was refractory to immunosuppression.
- NOTCH3 sequencing and/or deletion/duplication testing for suspected CADASIL or related cerebrovascular/cognitive disorder (ICD-10: I67.850, F02.80, F02.81).
- Genetic testing for hereditary epilepsy, neurodegenerative, or neuromuscular disorders to establish or confirm a diagnosis in patients with signs and/or symptoms of a genetic disorder when clinical evaluation and standard laboratory tests/imaging are non-diagnostic or inconclusive.
5 Active Policies
AMBETTER-CG-Epilepsy-Neurodegen-Neuromusc-DO-2025.1, Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions
CARELON-genetic-testing-for-inherited-conditions-2024-06-30-updated-01-20-2025, Genetic Testing for Inherited Conditions
REGENCE-GT20, Genetic and Molecular Diagnostic Testing
REGENCE-GT81, Reproductive Carrier Screening for Genetic Diseases
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.