Medical Policy Revisions related to Methylenetetrahydrofolate reductase (MTHFR)

Effective April 1, 2021, Horizon BCBSNJ will change the way we consider certain professional claims based on revisions to the following medical policies:

• Genetic Testing for Diagnosis and Management of Mental Health Conditions
• Genetic Testing for Inherited Thrombophilia
• Pharmacogenetic Testing for Pain Management

Access our Medical Policy Manual to review the content of these medical policies.

Claims submitted for services provided on and after April 1, 2021 will be processed as follows

• Regardless of the submitted diagnosis code(s), the services represented by CPT® code 81291 (Methylenetetrahydrofolate Reductase (MTHFR) Thermolabile Variant, DNA Analysis) included on claims for services rendered to patients enrolled in Horizon BCBSNJ commercial plans and Administrative Services Only (ASO) employer groups will be denied as experimental/investigational noncovered services.
• Regardless of the submitted diagnosis code(s), information will be requested to help us determine the medical appropriateness of the services represented by CPT code 81291 included on claims for services rendered to patients enrolled in Horizon BCBSNJ Medicare Advantage plans.
• Following our review of medical record information, these services may be denied as “not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, based on a national coverage determination or local coverage determination.”

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