S3866, Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy
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 may be required to submit clinical documentation in support of a request for services. Such documentation must a) accurately reflect the clinical situation at the time of the requested service, and b) sufficiently document the ordering provider’s clinical intent.
- The clinical utility of PGT-M is firmly established.
- Requests may require submission of clinical documentation that accurately reflects the clinical situation and documents the ordering provider's clinical intent.
- Pre‑test genetic counseling is strongly recommended and should cover family/medical history interpretation, education about inheritance and testing limitations, informed choices, and psychological aspects.
Key Coverage Criteria
- Genetic testing is considered medically necessary for an individual when ALL the following criteria are met.
- The individual is either suspected to have a known genetic condition based on clinical presentation or the individual may be pre-symptomatic but at significant risk based on family history.
- The genetic disorder being evaluated has clearly defined gene(s) and pathogenic variants associated with it and the associated test has high sensitivity and specificity to guide clinical decision making.
- The genetic testing has established analytical and clinical validity and is performed in an appropriately accredited and certified laboratory.
- Alternate, biochemical, or other clinical tests are not available, provide an indeterminate result or are less effective than genetic testing.
- The natural history of the disease is associated with significant morbidity and or mortality in affected individuals.
3 Active Policies
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
CARELON-genetic-testing-for-inherited-conditions-2025-09-20-updated-2026-04-01, Genetic Testing for Inherited Conditions
Related Codes
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