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Medical Policy Revision: Pharmacogenetic Testing for Pain Management

Effective September 5, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for pharmacogenetic testing for pain management.

According to the guidelines of our medical policy, Pharmacogenetic Testing for Pain Management, genetic testing for pain management is considered investigational for all indications.

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

Based on the guidelines of our medical policy, Pharmacogenetic Testing for Pain Management:

  • CPT® codes 81225 and/or 81227 submitted on claims for services provided on and after September 5, 2016 will be denied as investigational services regardless of the submitted diagnosis code(s).
  • Claims that include CPT code 81291 for services provided on and after September 5, 2016 when submitted with certain diagnosis code(s) will pend while information is requested and reviewed to help us determine if the service in question is to be considered medically necessary or investigational.
  • Claims that include CPT code 81401 for services provided on and after September 5, 2016 will pend (when submitted with certain diagnosis) while information is requested and reviewed to help us determine if the service 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.

Published on: June 7, 2016, 09:33 a.m. ET
Last updated on: November 25, 2020, 00:24 a.m. ET