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Medical Policy Implementation: Genetic Testing for Duchenne and Becker Muscular Dystrophy

Effective February 15, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for genetic testing for Duchenne and Becker Muscular Dystrophy (DMD).

According to the guidelines of our medical policy, Genetic Testing for Duchenne and Becker Muscular Dystrophy:

  • Genetic testing for DMD gene mutations is considered medically necessary under the following conditions:
    • In a male with signs and symptoms of dystrophinopathy in order to confirm the diagnosis and direct treatment.
    • For at-risk female relatives: to confirm or exclude the need for cardiac surveillance, and; for preconception testing to determine the likelihood of an affected offspring in a woman considering pregnancy.
  • Genetic testing for DMD gene mutations is considered investigational for all other indications.

We strongly encourage you to review this entire in our online Medical Policy Manual.

Based on the guidelines of our medical policy, Genetic Testing for Duchenne and Becker Muscular Dystrophy AND the submitted diagnosis code(s), claims for services provided on after February 15, 2016 that include CPT® codes 81161 or 81408 may pend while information to determine medical appropriateness is requested and reviewed.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after February 15, 2016.

CPT® is a registered mark of the American Medical Association.

Published on: November 16, 2015, 08:00 a.m. ET
Last updated on: November 24, 2020, 23:48 p.m. ET