Pharmacogenomic Testing - Priority Health

Summary of Changes 

MEDICAL POLICY 

No. 91570-R5 

PHARMACOGENOMIC TESTING 

Effective Date: February 26, 2015 Review Dates: 2/10, 2/11, 2/12, 2/13, 2/14, 2/15 

Date Of Origin: February 10, 2010 

Status: Current 

Clarifications: 

• Pg 1, Section I, language updated to clarify the criteria that must be met for pharmacogenetic 

testing to be considered medically necessary. 

• Pg 1, Section I, A, polymorphisms added to section heading. 

• Pg 2, Section I, A, Genotyping for other Cytochrome P450 polymorphisms language updated to 

include beta blockers. 

• Pg 5, Section IV, descriptive information formerly in Section I, A, moved to the description 

section of the policy. 

Deletions: 

• 

Additions: 

• Pg 2, Section I, A, CYP2D6 genotyping is considered to be experimental and investigational for 

identifying individuals with Alzheimer's disease with different clinical response to donepezil 

(Aricept) because its clinical value has not been established. 

• Pg 4, Section I, K, Genetic testing that is specified as a requirement for drug treatment per the 

FDA is considered medically necessary. 

• Pg 13, Appendix I, Non-Covered Testing list updated to include SuperGene (STAR), Millennium 

PGT and PersonaGene Genetic Panels. 

I. POLICY/CRITERIA 

In general pharmacogenetic testing (e. g., genotyping, mutation analysis) is only 

considered to be medically necessary when the following criteria is met (this list 

may not be all inclusive): 

• The individual is a candidate for a targeted drug therapy associated with a 

specific gene biomarker or gene mutation. 

• The results of the pharmacogenetic test will directly impact clinical 

decision-making AND clinical outcome for the individual. 

• The testing method is considered to be scientifically valid to identify the 

specific gene biomarker or gene mutation. 

• The testing method has been scientifically proven to show a relationship 

between a specific gene biomarker or gene mutation and a specific 

therapeutic drug target. 

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No. 91570-R5 

Pharmacogenomic Testing 

A. Cytochrome P450 (CYP450) polymorphisms 

• Genotype testing for identification of the CYP2C19 variant of 

Cytochrome P450 to determine the drug-metabolizer status of individuals: 

a) who are currently undergoing treatment with clopidogrel and have not 

been tested, or b) for whom the use of clopidogrel is being proposed, is 

considered medically necessary. Repeat CYP2C19 genotyping has no 

proven value. 

• Genotyping for CYP2D6 polymorphisms is medically necessary for 

persons who have been prescribed doses of tetrabenazine (Xenazine) 

greater than 50 mg per day. Repeat CYP2D6 genotyping has no proven 

value. 

• Genotyping for other Cytochrome P450 polymorphisms (including those 

associated with warfarin, tamoxifen, proton pump inhibitors, beta blockers 

and selective serotonin reuptake inhibitors (anti-psychotropics) is 

considered to be experimental and investigational because the clinical 

value of this type of genetic testing has not been established 

• CYP2D6 genotyping is considered to be experimental and 

investigational for identifying individuals with Alzheimer's disease with 

different clinical response to donepezil (Aricept) because its clinical value 

has not been established. 

B. Thiopurine S-methyltransferase (TPMT) genetic polymorphism 

1. TPMT gene mutation assays (e.g., PRO-Predict R TPMT) or TPMT 

phenotypic assays (Thiopurine metabolite testing, TPMT enzymatic 

activity, e.g., PRO-Predict R EnzAct) medically necessary prior to initiation 

of 6-mercaptopurine or azathioprine therapy. Only one genotypic or 

phenotypic assay of TPMT activity is necessary per member per lifetime. 

2. TPMT gene mutation assays and TPMT phenotypic assays are considered 

experimental and investigational for all other indications. 

C. HLA-B*1502 

Genotyping for HLA-B*1502 is considered to be medically necessary for 

persons of Asian ancestry before commencing treatment with carbamazepine 

(Tegretol). B*1502, an HLA allele is strongly associated with carbamazepineinduced 

Stevens-Johnson syndrome/toxic epidermal necrolysis in south-east 

Asians. 

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No. 91570-R5 


D. HLA-B*5701 for Abacavir hypersensitivity 

HLA-B*5701 screening is considered to be medically necessary for persons 

infected with HIV-1 before commencing treatment with abacavir (Ziagen). 

E. KRAS Mutation Assay 

Testing is considered to be medically necessary ONLY prior to initiation of 

epidermal growth factor receptor (EGFR) inhibitor therapies cetuximab 

(Erbitux®) and panitumumab (Vectibix®) for the treatment of metastatic 

colorectal cancer. 

F. CFTR G551D Mutation Analysis 

Testing to detect the G551D mutation in the CTFR gene is considered to be 

medically necessary for persons with cystic fibrosis who are being considered 

for treatment with ivacaftor (Kalydeco). 

G. EGFR Mutation Analysis 

Testing for the presence of a characteristic mutation in the epidermal growth 

factor receptor (EGFR) is considered to be medically necessary to determine a 

subset of patients with non-small cell lung cancer (NSCLC) who are likely to 

have a favorable response to EGFR tyrosine kinase inhibitors (TKIs). 

H. BRAF V600E or V600K 

BRAF V600E or V600K mutation testing is considered medically necessary 

for persons who are considering vemurafenib (Zelboraf) for the treatment of 

unresectable or metastatic melanoma 

I. Anaplastic lymphoma kinase (ALK) fusion gene 

ALK testing is considered medically necessary for persons who are 

considering crizotinib (Xalkori) for the treatment of non-small cell lung 

cancer (NSCLC). 

J. MGMT (O(6)-methylguanine-DNA methyltransferase) 

MGMT gene methylation assay is considered medically necessary for 

predicting response to temozolomide (Temodar) in persons with glioblastoma. 

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No. 91570-R5 


K. Genetic testing for FDA approved drug treatments 

Genetic testing that is specified as a requirement for drug treatment per the 

FDA is considered medically necessary. 

II. 

MEDICAL NECESSITY REVIEW 

Selected tests require prior authorization. Refer to Section V, Coding 

Information, for specific prior authorization requirements for testing by CPT 

code. 

All tests performed at non-participating laboratories will require prior 

authorization for all products. 

III. 

APPLICATION TO PRODUCTS 

Coverage is subject to member’s specific benefits. Group specific policy will 

supersede this policy when applicable. 

HMO/EPO: This policy applies to insured HMO/EPO plans. 

POS: This policy applies to insured POS plans. 

PPO: This policy applies to insured PPO plans. Consult individual plan documents as 

state mandated benefits may apply. If there is a conflict between this policy and a plan 

document, the provisions of the plan document will govern. 

ASO: For self-funded plans, consult individual plan documents. If there is a conflict 

between this policy and a self-funded plan document, the provisions of the plan document 

will govern. 

INDIVIDUAL: For individual policies, consult the individual insurance policy. If there is 

a conflict between this medical policy and the individual insurance policy document, the 

provisions of the individual insurance policy will govern. 

MEDICARE: Coverage is determined by the Centers for Medicare and Medicaid Services 

(CMS); if a coverage determination has not been adopted by CMS, this policy applies. 

MEDICAID/HEALTHY MICHIGAN PLAN: For Medicaid/Healthy Michigan Plan 

members, this policy will apply. Coverage is based on medical necessity criteria being met 

and the appropriate code(s) from the coding section of this policy being included on the 

Michigan Medicaid Fee Schedule located at: http://www.michigan.gov/mdch/0,1607,7- 

132-2945_42542_42543_42546_42551-159815--,00.html. If there is a discrepancy between 

this policy and the Michigan Medicaid Provider Manual located at: 

http://www.michigan.gov/mdch/0,1607,7-132-2945_5100-87572--,00.html, the Michigan 

Medicaid Provider Manual will govern. For Medical Supplies/DME/Prosthetics and 

Orthotics, please refer to the Michigan Medicaid Fee Schedule to verify coverage. 

MICHILD: For MICHILD members, this policy will apply unless MICHILD certificate of 

coverage limits or extends coverage. 

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No. 91570-R5 


IV. 

DESCRIPTION 

The CYP450 test was developed as a clinical test to evaluate an individual's 

metabolic capacity for certain drugs by identifying polymorphisms of 2 CYP450 

enzymes CYP2D6 and CYP2D19). Pharmacogenetic factors operate at 

pharmacokinetic as well as pharmacodynamic levels- the two components of the 

dose-response curve of a drug. Polymorphisms in drug metabolizing enzymes, 

transporters and/or pharmacological targets of drugs may profoundly influence 

the dose-response relationship between individuals 

Pharmacogenomics is a science that examines the inherited variations in genes 

that dictate drug response and explores the ways these variations can be used to 

predict whether a patient will have a good response to a drug, a bad response to a 

drug, or no response at all. The term comes from the words pharmacology and 

genomics and is thus the intersection of pharmaceuticals and genetics. 

V. CODING INFORMATION 

ICD-9 Codes that may support medical necessity 

See criteria 

CPT/HCPCS Codes 

May be covered if criteria is met 

* Prior Authorization required 

81210* BRAF (v-raf murine sarcoma viral oncogene homolog B1) (eg, colon cancer), 

gene analysis, V600E variant 

81221 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic 

fibrosis) gene analysis; known familial variants 

81225 CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug 

metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17) 

81226 CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug 

metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, 

*17, *19, *29, *35, *41, *1XN, *2XN, *4XN) 

81227 CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg, drug 

metabolism), gene analysis, common variants (eg, *2, *3, *5, *6) 

81235* EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene 

analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, 

G719A, G719S, L861Q) 

81275 KRAS (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) (eg, carcinoma) gene 

analysis, variants in codons 12 and 13 

81287 MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma 

multiforme), methylation analysis 

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No. 91570-R5 


81381* HLA Class I typing, high resolution (ie, alleles or allele groups); 1 allele or 

allele group (eg, B*57:01P), each 

81382* HLA Class II typing, high resolution (ie, alleles or allele groups); one locus 

(eg, HLA-DRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, or -DPA1), each 

81383* HLA Class II typing, high resolution (ie, alleles or allele groups); 1 allele or 

allele group (eg, HLA-DQB1*06:02P), each 

81401 Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated variant, 

or 1 somatic variant [typically using nonsequencing target variant analysis], or 

detection of a dynamic mutation disorder/triplet repeat) 

81403 Molecular pathology procedure, Level 4 (eg, analysis of single exon by DNA 

sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or 

more independent reactions, mutation scanning or duplication/deletion variants 

of 2-5 exons) 

81405 Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA 

sequence analysis, mutation scanning or duplication/deletion variants of 11-25 

exons, regionally targeted cytogenomic array analysis) 

81406 Molecular pathology procedure, Level 7 (eg, analysis of 11-25 exons by DNA 

sequence analysis, mutation scanning or duplication/deletion variants of 26-50 

exons, cytogenomic array analysis for neoplasia) 

88271 Molecular cytogenetics; DNA probe, each (eg, FISH) 

88274 Molecular cytogenetics; interphase in situ hybridization, analyze 25-99 cells 

88367 Morphometric analysis, in situ hybridization (quantitative or semiquantitative), 

using computer-assisted technology, per specimen; initial single 

probe stain procedure 

88368 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative) 

each probe; manual 

88377 Morphometric analysis, in situ hybridization (quantitative or semiquantitative), 

manual, per specimen; each multiplex probe stain procedure 

NOT COVERED (See Appendix I) – List should not be considered inclusive of every 

possible billing scenario or code) 

“S” codes will no longer be accepted in lieu of CPT codes for any genetic related testing 

Invader UGT1A1 molecular 

assay 

Vitamin K epoxide 

reductase-oxidase complex 

gene (VKORC1) 

81350 UGT1A1 (UDP glucuronosyltransferase 1 family, 

polypeptide A1) (eg, irinotecan metabolism), gene 

analysis, common varia nts (eg, *28, *36, *37) 

81355 VKORC1 (vitamin K epoxide reductase complex, 

subunit 1) (eg, warfarin metabolism), gene analysis, 

common variants (eg, -1639/3673) 

G9143 Warfarin responsiveness testing by genetic technique 

using any method, any number of specimen(s) May 

be covered under Clinical Trial processing for 

Medicare 

Apolipoprotein E (Apo E) 

82172 Apolipoprotein, each 

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No. 91570-R5 


Methylenetetrahydrofolate 

reductase (MTHFR) 

Dihydropyrimidine 

dehydrogenase (DPD) 

testing (e.g., enzyme or 

DNA testing) 

Excision repair crosscomplementation 

group 1 

(ERCC1) 

Gene expression profiling 

(e.g., Decision Dx-GBM) 

Thromboxane metabolites 

rs3798220 allele testing 

OnDose (AUC-targeted 5- 

fluorouracil) 

Testing for polymorphisms 

of dihydropyrimidine 

dehydrogenase and 

thymidylate synthase 

IL28B polymorphism 

genotyping 

81291 MTHFR (5,10-methylenetetrahydrofolate reductase) 

(eg, hereditary hypercoagulability) gene analysis, 

common variants (eg, 677T, 1298C) 

81400 Molecular pathology procedure, Level 1(eg, 

identification of single germline variant [eg, SNP] by 

techniques such as restriction enzyme digestion or 

melt curve analysis) 

88360 Morphometric analysis, tumor immunohistochemistry 

(eg, Her-2/neu, estrogen receptor/progesterone 

receptor), quantitative or semiquantitative, each 

antibody; manual 

88361 Morphometric analysis, tumor immunohistochemistry 

(eg, Her-2/neu, estrogen receptor/progesterone 

receptor), quantitative or semiquantitative, each 

antibody; using computer-assisted technology 

See Unlisted Codes 

84431 Thromboxane metabolite(s), including thromboxane if 

performed, urine 







81401 Molecular pathology procedure, Level 2 (eg, 2-10 

SNPs, 1 methylated variant, or 1 somatic variant 

[typically using nonsequencing target variant 

analysis], or detection of a dynamic mutation 

disorder/triplet repeat) 





GeneSightRx testing 81225 CYP2C19 (cytochrome P450, family 2, subfamily C, 

polypeptide 19) (eg, drug metabolism), gene analysis, 

common variants (eg, *2, *3, *4, *8, *17) 

81226 CYP2D6 (cytochrome P450, family 2, subfamily D, 


common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, 

*19, *29, *35, *41, *1XN, *2XN, *4XN) 

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No. 91570-R5 


81227 CYP2C9 (cytochrome P450, family 2, subfamily C, 


common variants (eg, *2, *3, *5, *6) 






Platelet reactivity/function 

testing (VerifyNow P2Y12 

Assay) 

Galectin-3 

ImmuKnow Assay (aka 

Transplantation Immune 

Cell Function Assay) 

Genecept (Genomind) 

85576 Platelet, aggregation (in vitro), each agent 

82777 Galectin-3 

86352 Cellular function assay involving stimulation (eg, 

mitogen or antigen) and detection of biomarker (eg, 

ATP) 


Beta andrenergic receptor 

genotyping 






+VectraDA 83520 Immunoassay for analyte other than infectious agent 

antibody or infectious agent antigen; quantitative, not 

otherwise specified 

86140 C-reactive protein 

Millennium PGT 

PersonaGene Genetic 

Panels 




common variants (eg, *2, *3, *4, *8, *17) 

81226 CYP2D6 (cytochrome P450, family 2, subfamily D, 


common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, 

*19, *29, *35, *41, *1XN, *2XN, *4XN) 



common variants (eg, *2, *3, *5, *6) 

81240 F2 (prothrombin, coagulation factor II) (eg, hereditary 

hypercoagulability) gene analysis, 20210G>A variant 

81241 F5 (coagulation Factor V) (eg, hereditary 

hypercoagulability) gene analysis, Leiden variant 


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No. 91570-R5 






81291 MTHFR (5,10-methylenetetrahydrofolate reductase) 

(eg, hereditary hypercoagulability) gene analysis, 

common variants (eg, 677T, 1298C) 

Unlisted\Miscellaneous Codes – Explanatory notes must accompany claim 

81479 Unlisted molecular pathology procedure 

81599 Unlisted multianalyte assay with algorithmic analysis 

88299 Unlisted cytogenetic study 

VI. 

REFERENCES 

BlueCross BlueShield Association (BCBSA), Technology Evaluation Center 

(TEC). Special Report: Genotyping for cytochrome P450 polymorphisms to 

determine drug-metabolizer status. TEC Assessment Program. Chicago, IL: 

BCBSA; December 2004;19(9). Available at: 

http://www.bcbs.com/tec/vol19/19_09.html. 

The AmpliChip CYP450 Test: Principles, Challenges, and Future Clinical Utility 

in Digestive Disease. Clin Gastroenterol Hepatol. 2006 Jul;4(7):822-30. 

Epub 2006 Jun 22. 

Pharmacogenetics in drug regulation: promise, potential and pitfalls. 

Philos Trans R Soc Lond B Biol Sci. 2005 Aug 29;360(1460):1617-38. 

Review 

Applications of AmpliChip CYP450. Mol Diagn. 2005;9(3):119-27. 

GeneTests http://www.genetests.org NIH sponsored website 

Circulation. 2007;116(22):2563-2570 Randomized trial of genotype-guided 

versus standard warfarin dosing in patients initiating oral anticoagulation. 

Anderson JL, Horne BD, Stevens SM, et al.. 

Pharmacother. Ann 2008;42(9):1298-1303. Genetic testing for warfarin therapy 

initiation. Hynicka LM, Cahoon WD, Bukaveckas BL 

Genet Med. 2009 Jan;11(1):21-34.Can UGT1A1 genotyping reduce morbidity 

and mortality in patients with metastatic colorectal cancer treated with 

irinotecan? An evidence-based review. Palomaki GE, Bradley LA, Douglas 

MP, Kolor K, Dotson WD. 

Genet Med. 2009 Jan;11(1):15-20. Recommendations from the EGAPP Working 

Group: can UGT1A1 genotyping reduce morbidity and mortality in patients 

with metastatic colorectal cancer treated with irinotecan? Evaluation of 

Genomic Applications in Practice and Prevention (EGAPP) Working Group. 

Curr Pharm Des. 2009 Oct 15. [Epub ahead of print]Pharmacogenetics of Oral 

Anticoagulant Therapy. Schalekamp T, de Boer A. 

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No. 91570-R5 


Clin Pharmacokinet. 2008;47(9):565-94. Pharmacogenetics of oral anticoagulants: 

a basis for dose individualization. Stehle S, Kirchheiner J, Lazar A, Fuhr 

U. 

Curr Opin Allergy Clin Immunol. 2007 Aug;7(4):317-23. Human leukocyte 

antigens and drug hypersensitivity. Chung WH, Hung SI, Chen YT. 

Pharmacogenet Genomics. 2009 Sep;19(9):704-9. Strong association between 

HLA-B*5801 and allopurinol-induced Stevens-Johnson syndrome and 

toxic epidermal necrolysis in a Thai population. Tassaneeyakul W, et.al. 

Tissue Antigens. 2009 Oct 15. [Epub ahead of print] Successful implementation 

of a national HLA-B*5701 genetic testing service in Canada. Lalonde 

RG,et.al. 

Pharmacogenet Genomics. 2006 May;16(5):353-7. A sensitive and rapid 

alternative to HLA typing as a genetic screening test for abacavir 

hypersensitivity syndrome. Martin AM, Krueger R, Almeida CA, Nolan 

D, Phillips E, Mallal S. 

Pharmacogenetics. 2004 Jun;14(6):335-42. Cost-effectiveness analysis of HLA 

B*5701 genotyping in preventing abacavir hypersensitivity. Hughes DA, 

Vilar FJ, Ward CC, Alfirevic A, Park BK, Pirmohamed M. 

Reviews of selected pharmacogenetic tests for non-cancer and cancer condtions. 

Technology Assessment Report. Prepared by the Tufts Evidence-based 

Practice Center for the Agency for Healthcare Research and Quality 

(AHRQ). Contract No. 290-02-0022. Rockville, MD: AHRQ; November 

12, 2008. Raman G, Trikalinos TA, Zintzaras E, et al Available at: 

http://www.cms.hhs.gov/determinationprocess/downloads/id61TA.pdf 

Am J Epidemiol. 2004 Sep 1;160(5):421-9. Familial hypercholesterolemia and 

coronary heart disease: a HuGE association review. Austin MA, Hutter 

CM, Zimmern RL, Humphries SE. 

Int J Mol Med. 2003 May;11(5):593-600. Polymorphisms in the thymidylate 

synthase and methylenetetrahydrofolate reductase genes and sensitivity to 

the low-dose methotrexate therapy in patients with rheumatoid arthritis. 

Kumagai K, Hiyama K, Oyama T, Maeda H, Kohno N. 

Ann Rheum Dis. 2005 Aug;64(8):1180-5. Epub 2005 Jan 27. Pharmacogenetic 

and metabolite measurements are associated with clinical status in patients 

with rheumatoid arthritis treated with methotrexate: results of a 

multicentred cross sectional observational study. Dervieux T, Furst D, 

Lein DO, Capps R, Smith K, Caldwell J, Kremer J. 

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No. 91570-R5 


Test 

Invader UGT1A1 

molecular assay 

Vitamin K epoxide 

reductase-oxidase complex 

gene (VKORC1) 

Apolipoprotein E (Apo E) 

Methylenetetrahydrofolate 

reductase (MTHFR) 

Dihydropyrimidine 

dehydrogenase (DPD) 

testing (e.g., enzyme or 

DNA testing) 

Excision repair crosscomplementation 

group 1 

(ERCC1) 

Gene expression profiling 

(e.g., Decision Dx-GBM) 

Thromboxane metabolites 

rs3798220 allele testing 

OnDose (AUC-targeted 5- 

fluorouracil) 

Testing for polymorphisms 

of dihydropyrimidine 

APPENDIX I 

Non-Covered Testing 

Last Update: 2/2015 

Application 

Uridine diphosphate glucuronosyl transferase 1A1 

(UGT1A1) gene polymorphisms for determining the proper 

dosage of irinotecan for persons with colorectal cancer or 

other types of cancer. No intervention trials have shown 

that targeted dosing of irinotecan based on UGT1A1 

genotyping could reduce the rates of two specific adverse 

drug events, severe (Grade 3-4) neutropenia or diarrhea 

Genotyping for VKORC1 polymorphism (diagnostic tests 

to identify specific genetic variations that may be linked to 

reduced/enhanced effect or severe side effects of drugs 

metabolized by the the vitamin K epoxide reductase 

complex subunit 1 gene including warfarin) 

Genotyping for apolipoprotein E (Apo E) for determining 

therapeutic response to lipid-lowering medications 

Genotyping for methylenetetrahydrofolate reductase 

(MTHFR) for determining therapeutic response to 

antifolate chemotherapy 

To predict or monitor response to fluorouracil (5-FU) or 

capecitabine (Xeloda®) chemotherapy 

To predict benefit from adjuvant platinum-based 

chemotherapy (e.g., cisplatin, carboplatin, oxaliplatin) 

For the management of glioblastoma to predict outcome 

and treatment response 

Measurement of thromboxane metabolites in urine (e.g., 

AspirinWorks) to evaluate aspirin resistance experimental 

and investigational because its clinical value has not been 

established 

Genetic testing for the rs3798220 allele experimental and 

investigational for selecting persons for chronic aspirin 

therapy or other indications because its clinical value has 

not been established 

Area under the curve (AUC)-targeted 5-fluorouracil dosing 

(e.g., Myriad Genetics’ OnDose) experimental and 

investigational because its clinical value has not been 

established. 

Testing for genetic polymorphisms of dihydropyrimidine 

dehydrogenase and thymidylate synthase to predict 5- 

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No. 91570-R5 


dehydrogenase and 

thymidylate synthase 

IL28B polymorphism 

genotyping 

GeneSightRx or 

SuperGene (STAR) testing 

Platelet reactivity/function 

testing (VerifyNow P2Y12 

Assay) 

Galectin-3 

Advise PG 

ImmuKnow Assay (aka 

Transplantation Immune 

Cell Function Assay) 

Genecept (Genomind) 

Beta adrenergic receptor 

genotyping 

+VectraDA 

Millennium PGT 

PersonaGene Genetic 

Panels 

fluorouracil toxicity experimental and investigational 

because the clinical value of such testing has not been 

established 

IL28B polymorphism genotyping for interferon therapy for 

hepatitis C experimental and investigational because its 

clinical value has not been established 

GeneSightRx or STAR testing for the management of 

individuals treated with anti-depressant and/or antipsychotic 

medications experimental and investigational 

because its clinical value has not been established. 

Platelet reactivity/function testing (VerifyNow P2Y12 

Assay) for individuals who have undergone percutaneous 

coronary intervention experimental and investigational 

because its clinical value has not been established. 

For cardiac resynchronization therapy and all other 

indications (e.g., prognosis of heart failure) 

Measures the level of methotrexate (MTX) polyglutamates, 

the active metabolites of methotrexate. Use of the Avise PG 

test has been suggested for patients that have been taking 

MTX for at least three months and have not obtained 

significant relief from their RA symptoms. 

Cellular function assay involving stimulation (eg, mitogen 

or antigen) and detection of biomarker (eg, ATP) 

Physiological and genetic profile for patients with 

conditions including depression, bipolar disorder, 

schizophrenia, anxiety disorders, OCD and ADHD 

Experimental and investigational for evaluating persons 

with treatment resistant asthma and for all other 

indications. 

Experimental and investigational for assessment of disease 

activity in RA patients 

Experimental and investigational for management of 

medications for chronic pain and for all other indications 

Experimental and investigational for making medication 

adjustments and for all other indications. 

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No. 91570-R5 


AMA CPT Copyright Statement: 

All Current Procedure Terminology (CPT) codes, descriptions, and other data are copyrighted by the 

American Medical Association. 

This document is for informational purposes only. It is not an authorization, certification, explanation of 

benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage. 

Eligibility and benefit coverage are determined in accordance with the terms of the member’s plan in effect 

as of the date services are rendered. Priority Health’s medical policies are developed with the assistance 

of medical professionals and are based upon a review of published and unpublished information including, 

but not limited to, current medical literature, guidelines published by public health and health research 

agencies, and community medical practices in the treatment and diagnosis of disease. Because medical 

practice, information, and technology are constantly changing, Priority Health reserves the right to review 

and update its medical policies at its discretion. 

Priority Health’s medical policies are intended to serve as a resource to the plan. They are not intended to 

limit the plan’s ability to interpret plan language as deemed appropriate. Physicians and other providers 

are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels 

of care and treatment they choose to provide. 

The name “Priority Health” and the term “plan” mean Priority Health, Priority Health Managed Benefits, 

Inc., Priority Health Insurance Company and Priority Health Government Programs, Inc. 

Page 13 of 13

Pharmacogenomic Testing - Priority Health

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