Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders

This policy covers genetic and molecular testing for immune, autoimmune, and rheumatoid disorders — including inherited immunodeficiencies, multigene periodic fever panels, RA disease-activity and biomarker panels (e.g., Vectra), TNF‑inhibitor response algorithmic tests (e.g., PrismRA), and HLA‑B27 typing — when ordered for patients with clinical features of these conditions (e.g., suspected periodic fever syndromes, diagnosed moderate-to-severe RA, axial spondyloarthritis). Coverage is limited to adults (≥18) who meet specific clinical criteria (for example, ≥3 unexplained fevers in 6 months for periodic fever panels; prior csDMARD failure/intolerance and sufficient RA severity for TNFi predictive testing), requires exclusion of alternative causes and documentation per the General Approach to Genetic and Molecular Testing policy, and deems several tests investigational or noncovered outside the stated indications.

"Genetic testing for inherited immunodeficiency disorders"