Forms and Documents Search Results

Skip to Content


Back to Search

Medical Policies

Page of 2, showing Documents 1-10 of 19

Documents for Medical Policies

  • /app/files/public/4586/pdf-medicalpolicies-9012Gene.pdf Genetic Testing Show Details
    Description
    (MP9012) (GTMP) Genetic testing is a covered benefit for Dean Health Plan members, only if the test results provide a direct medical benefit or guides reproductive decision-making for the Dean Health Plan member. Related codes: 81243, 81244, 81256, 81332, 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81415, 81416, 81417, 81425, 81426, 81427, 81432, 81433, 81434, 81445, 81479, 82103, 82104, S3800
    Last Updated
    8/1/2017
  • /app/files/public/9713/Genetic-Testing-for-BRCA1-and-BRCA2-Genes.pdf Genetic Testing for BRCA1 and BRCA2 Genes Show Details
    Description
    (MP9478) (GTMP) Molecular susceptibility testing for breast and/or epithelial ovarian cancer (BRCA testing) requires prior authorization through the Quality and Care Management Division. Related codes: 81162, 81211, 81213, 81214, 81215, 81216, 81217, 81312, 81432, 81433
    Last Updated
    5/3/2017
  • /app/files/public/9696/Genetic-Testing-for-Chromosomal-Microarray-Analysis.pdf Genetic Testing for Chromosomal Microarray Analysis Show Details
    Description
    (MP9491) (GTMP) Chromosomal microarray analysis (CMA) does not require prior authorization and is medically necessary for the conditions listed in the medical policy. Related codes: 81228, 81229, S3870
    Last Updated
    5/3/2017
  • /app/files/public/9701/Genetic-Testing-for-Cowden-Syndrome-PTEN-Gene.pdf Genetic Testing for Cowden Syndrome Show Details
    Description
    (MP9488) (GTMP) Genetic testing for Cowden Syndrome (CS) requires prior authorization through the Quality and Care Management. PTEN gene testing is considered medically necessary in individuals with a suspected or known clinical diagnosis of Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome (BRRS), or a known family history of a PTEN mutation who meet the medical policy criteria. Related codes: 81321, 81322, 81323, 81403, 81435, 81436, 81445
    Last Updated
    5/3/2017
  • /app/files/public/9706/Genetic-Testing-for-Diffuse-Gastric-Cancer.pdf Genetic Testing for Diffuse Gastric Cancer Show Details
    Description
    (MP9484) (GTMP) Genetic testing for Diffuse Gastric Cancer (DGC) requires prior authorization through the Quality and Care Management Division. CDH1 genetic testing is considered medically necessary in individuals when the medical policy criteria are met. Related codes: 81403, 81406
    Last Updated
    5/3/2017
  • /app/files/public/9710/Genetic-Testing-for-Hearing-Loss-and-Usher-Syndrome.pdf Genetic Testing for Hearing Loss and Usher Syndrome Show Details
    Description
    (MP9481) (GTMP) Usher syndrome, CDH23, CIB2, CLRN1, DFNB1, DFNB31, GPR98, HARS, MYO7A, PCDH15, USH1C, USH1G, USH2A, PDZD7, SANS, ABHD12 and WHRN genetic testing requires prior authorization through the Quality and Care Management Division. Related codes: 81252, 81253, 81254, 81404, 81407, 81408, 81430, 81431
    Last Updated
    5/3/2017
  • /app/files/public/9716/Genetic-Testing-for-Hereditary-Cardiac-Disease-and-Arrhythmias.pdf Genetic Testing for Hereditary Cardiac Disease and Arrhythmias Show Details
    Description
    (MP9472) (GTMP) Confirmatory (Diagnostic) Genetic Testing for hereditary arrhythmias, Brugada Syndrome (BrS), Long QT Syndrome, Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) and/or cardiomyopathies requires prior authorization through the Quality and Care Management Division. Related codes: 81403, 81404, 81405, 81406, 81407, 81408, 81413, 81414, 81439, S3861, S3865, S3866
    Last Updated
    5/3/2017
  • /app/files/public/9700/Genetic-Testing-for-Huntington-Disease.pdf Genetic Testing for Huntington Disease Show Details
    Description
    (MP9490) (GTMP) Huntington Disease Genetic Testing (HTT) gene testing requires prior authorization through the Quality and Care Management Division and is considered medically necessary when the medical policy criteria are met. Related Code: 81401
    Last Updated
    5/3/2017
  • /app/files/public/9704/Genetic-Testing-for-Li-Fraumeni-Syndrome-LFS-TP53pdf.pdf Genetic Testing for Li-Fraumeni Syndrome Show Details
    Description
    (MP9485) (GTMP) Li-Fraumeni Syndrome (LFS) TP53 genetic testing requires prior authorization through the Quality and Care Management Division and is considered medically appropriate when the medical policy criteria are met. Related codes: 81403, 81404, 81405
    Last Updated
    5/3/2017
  • /app/files/public/9702/Genetic-Testing-for-Lynch-Syndrome.pdf Genetic Testing for Lynch Syndrome Show Details
    Description
    (MP9487) (GTMP) Genetic testing for Lynch Syndrome (EPCAM, MLH1, MSH2, and PMS2) requires prior authorization through the Quality and Care Management Division and is considered medically necessary when the medical policy criteria are met. Related codes: 81162, 81201, 81203, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81403, 81435, 81436
    Last Updated
    5/3/2017
  • Facebook
  • YouTube
  • LinkedIn
  • Twitter
  • Connect with us on Instagram

© 2017 SSM Health Dean Medical Group / Dean Health Plan, Inc. | All rights reserved.

A Member of SSM Health

SSM Health and the infinity symbol are trademarks of SSM Health and its affiliates.