Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective November 13, 2012 (Posted August 7, 2012)

Medical Policy Revision
Chromosomal Microarray (CMA) Analysis for Genetic Evaluation of Developmental Delay/Autism Spectrum Disorder "Notification" Description section updated. When Covered and When Not Covered sections updated. The following investigational statement was added: "Chromosomal microarray analysis is considered investigational in all other cases of suspected genetic abnormality in children with developmental delay/intellectual disability or autism spectrum disorder." The following not medically necessary statement was added: "Chromosomal microassay analysis to confirm the diagnosis of a disorder or syndrome that is routinely diagnosed based on clinical evaluation alone is not medically necessary." Policy guidelines updated. Specialty Matched Consultant Advisory Panel Review 7/18/12. Notification given 8/7/12 for policy effective date of 11/13/12
Genetic Testing for FMR1 Mutations Including Fragile X Syndrome "Notification" New policy developed. Genetic testing for FMR1 mutations may be considered medically necessary for the following patient populations: Individuals of either sex with mental retardation, developmental delay, or autism spectrum disorder, Individuals seeking reproductive counseling who have a family history of fragile X syndrome or a family history of undiagnosed mental retardation, Prenatal testing of fetuses of known carrier mothers, Affected individuals or their relatives who have had a positive cytogenetic fragile X test result who are seeking further counseling related to the risk of carrier status among themselves or their relatives. Genetic testing for FMR1 mutations is considered investigational in the absence of the above clinical indications. Medical Director review 7/2012. Policy noticed on 8/7/12 for effective date of 11/13/12.