Medical Policy Revision: Genetic Testing for Hereditary Pancreatitis

Effective September 5, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for genetic testing for hereditary pancreatitis.

According to the guidelines of our medical policy, Genetic Testing for Hereditary Pancreatitis, genetic testing for hereditary pancreatitis in members age 18 years and younger is considered medically necessary for members with unexplained recurrent acute or chronic pancreatitis with documented elevated amylase or lipase but is considered investigational in other situations.

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

Based on the guidelines of our medical policy, Genetic Testing for Hereditary Pancreatitis AND the submitted diagnosis code(s):

• Claims that include CPT® codes 81222, 81223, and/or 81401 for services provided to a member 18 years of age or younger on and after September 5, 2016 will pend when submitted with certain diagnosis code(s) while we request and review information to help us determine if the service in question is to be considered medically necessary or investigational.
• Claims that include CPT codes 81404 for services provided on and after September 5, 2016 will pend when submitted with certain diagnosis code(s) while we request and review information to help us determine if the service in question is to be considered medically necessary or investigational.

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 September 5, 2016.

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