GeneSight Psychotropic panel (by Assurex Health, Mason, OH)



    Purpose
    The purpose of this communication is to communicate the medically necessary position, (retro effective to 10/24/14), for the GeneSight Psychotropic panel (by Assurex Health, Mason, OH) for Company's Medicare Advantage Line of Business.

    Policy Impacted
    MA06.017a: Molecular Diagnostics

    Background
    Panels of multiple genetic tests have been developed to aid the diagnosis and treatment of mental health disorders. Genes included in the panels have shown some association with psychiatric disorders or with the pharmacokinetics of psychotropic medications.

    GeneSight® Psychotropic (by Assurex Health, Mason, OH) is a genetic panel that provides information about genes that may affect a patient’s response to antidepressant and antipsychotic pharmacotherapy. According to the manufacturer’s website, following testing, the treating provider receives a report with the most common medications for the patient’s diagnosed condition categorized by cautionary level, along with a report of the patient’s genetic variants. Details are not provided about the algorithm used by the manufacturer to generate risk levels.

    Coverage Statement

    MEDICALLY NECESSARY
    GeneSight Psychotropic panel is considered medically necessary and, therefore, covered when ordered by licensed psychiatrists contemplating an alteration in neuropsychiatric medication for patients diagnosed with major depressive disorder (MDD) (in accordance with DSM IV/V criteria) who are suffering with refractory moderate to severe depression (as defined by the 17-item Hamilton Rating Scale for Depression (HAM-D17) score of 14 or greater) after at least one prior neuropsychiatric medication failure.

    EXPERIMENTAL/INVESTIGATIONAL
    All other uses for GeneSight Psychotropic panel are considered experimental/investigational and, therefore, not covered.

    NOT MEDICALLY NECESSARY
    GeneSight Psychotropic panel is considered not medically necessary and, therefore, not covered when ordered/referred by any specialties other than licensed psychiatrists.

    REQUIRED DOCUMENTATION
    The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

    The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

    Coding

    THE FOLLOWING CODE IS USED TO REPRESENT GENESIGHT PSYCHOTROPIC PANEL:
    81479

    ICD-9 Coding for Coverage Positions for GeneSight Psychotropic Panel :
    296.20 Major depressive disorder, single episode, unspecified

    296.22 Major depressive disorder, single episode, moderate

    296.23 Major depressive disorder, single episode, severe, without mention of psychotic behavior

    296.24 Major depressive disorder, single episode, severe, specified as with psychotic behavior

    296.25 Major depressive disorder, single episode, in partial or unspecified remission

    296.30 Major depressive disorder, recurrent episode, unspecified

    296.32 Major depressive disorder, recurrent episode, moderate

    296.33 Major depressive disorder, recurrent episode, severe, without mention of psychotic behavior

    296.34 Major depressive disorder, recurrent episode, severe, specified as with psychotic behavior

    296.35 Major depressive disorder, recurrent episode, in partial or unspecified remission

    311 Depressive disorder, not elsewhere classified


    ICD-10 Coding for Coverage Positions for GeneSight Psychotropic Panel :
    F32.1 Major depressive disorder, single episode, moderate

    F32.2 Major depressive disorder, single episode, severe without psychotic features

    F32.3 Major depressive disorder, single episode, severe with psychotic features

    F32.4 Major depressive disorder, single episode, in partial remission

    F32.9 Major depressive disorder, single episode, unspecified

    F33.1 Major depressive disorder, recurrent, moderate

    F33.2 Major depressive disorder, recurrent severe without psychotic features

    F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms

    F33.40 Major depressive disorder, recurrent, in remission, unspecified

    F33.41 Major depressive disorder, recurrent, in partial remission

    F33.9 Major depressive disorder, recurrent, unspecified

    Issued on - 09/09/2015


Connect with Us        


© 2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.