BlueCross BlueShield of Tennessee Medical Policy Manual

Genetic Testing, Including Chromosomal Microarray Analysis and Next-Generation Sequencing Panels, for Prenatal Evaluation and Evaluation of Children with Developmental Delays/Intellectual Disability, Autism Spectrum Disorder and/or Congenital Anomalies

Does Not Apply to Commercial Genetic Testing Program effective 6/1/2018

DESCRIPTION

Chromosomal microarray (CMA) testing has been proposed for detection of genetic imbalances in infants or children with characteristics of developmental delay/intellectual disability, autism spectrum disorder and congenital anomalies, and to detect pathogenic fetal chromosomal abnormalities.  CMA technology has several advantages over karyotyping, including improved resolution (detection of smaller chromosomal variants that are undetectable using standard karyotyping) and, therefore, can result in higher rates of detection of pathogenic chromosomal abnormalities. CMA cannot detect balanced rearrangements, but can detect copy number variants (CNVs), and the frequency of disease-causing CNVs is highest (20%-25%) in children with moderate-to-severe intellectual disability accompanied by malformations or dysmorphic features.

Next generation sequencing (NGS) panel testing is another type of genetic testing that allows for simultaneous analysis of a large number of genes and has been proposed as a way to identify single-gene causes of syndromes that have autism as a significant clinical feature in individuals with normal CMA results.

POLICY

MEDICAL APPROPRIATENESS

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

The Tennessee state law applies to individual policies, fully insured accounts, and self-funded accounts that are not governed by ERISA (i.e. governmental plans and church plans). Please keep in mind that it can be very difficult to determine if such a Plan is a governmental plan, (for example some utilities are governmental plans), or a church plan (for example some hospital plans are church plans.) This mandate applies to such accounts that are delivered, issued for delivery, amended or renewed on or after January 1, 2007. This mandate does not apply to self-funded accounts that are governed by ERISA unless an ERISA governed self-funded account's plan language, Explanation of Coverage (EOC), or Summary Plan Description provides coverage for these particular disorders. An ERISA governed self-funded plan's language will govern application of this policy to a plan. In addition, other federal laws will preempt this provision. In particular, the Federal Employees Program is governed by federal law and contains a provision that preempts claims and benefits similar to ERISA.

The provisions of this mandate concern autism spectrum disorders and are applicable to individuals of less than twelve (12) years of age.

Tennessee Code Annotated, Title 56 Insurance, Chapter 7 Policies and Policyholders, Part 23 Mandated Insurer or Plan Coverage 56-7-2367. Autism spectrum disorders.

(a) As used in this section, "autism spectrum disorders" means neurological disorders, usually appearing in the first three (3) years of a person's life that affect normal brain functions and are typically manifested by impairments in communication and social interaction, as well as restrictive, repetitive, and stereotyped behaviors.

(b) A contract or policy of an insurer that provides benefits for neurological disorders, whether under an individual or group health insurance policy providing coverage on an expense-incurred basis, an individual or group service contract issued by a health maintenance organization, a self-insured group arrangement to the extent not preempted by federal law or a managed health care delivery entity of any type or description shall provide benefits and coverage for treatment of autism spectrum disorders that are at least as comprehensive as those provided for other neurological disorders. These benefits and coverage for treatment shall be provided to any person less than twelve (12) years of age.

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

The following are examples of Next Generation Sequencing (NGS) panel testing available: Greenwood Genetics Center offers an NGS panel for syndromic autism that includes 83 genes. The Emory Genetics Laboratory offers an NGS ASD panel. The clinical utility and effect on health care outcomes are not currently known.

SOURCES

Agency for Healthcare Research and Quality. (2015, June).  Genetic testing for developmental disabilities, intellectual disability, and autism spectrum disorder. Retrieved September 4, 2015 from www.ahrq.gov.

American Academy of Neurology. (2013). Model coverage policy: chromosomal microarray analysis for intellectual disabilities. Retrieved August 16, 2019 from http://www.neurology.org.

American Academy of Neurology. (March 2012). Evidence Report: Genetic and metabolic testing on children with global developmental delay: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Retrieved March 13, 2012 from http://www.neurology.org.

American Academy of Pediatrics (AAP). (2014). Comprehensive evaluation of the child with intellectual disability or global developmental delays. Retrieved September 8, 2017 from https://www.aap.org/.

American College of Medical Genetics and Genomics (ACMG). (2018). Yield of additional genetic testing after chromosomal microarray for diagnosis of neurodevelopmental disability and congenital anomalies: a clinical practice resource of the American College of Medical Genetics and Genomics (ACMG). Retrieved August 16, 2019 from https://www.acmg.net/.

American College of Obstetricians and Gynecologists. (December 2016). ACOG committee opinion # 682. Microarrays and next-generation sequencing technology: the use of advanced genetic diagnostic tools in obstetrics and gynecology. Retrieved September 9, 2017 from https://www.acog.org.

BlueCross BlueShield Association. Evidence Positioning System. (10:2018). Genetic testing for developmental delay/intellectual disability, autism spectrum disorder, and congenital anomalies (2.04.59) Retrieved August 16, 2019 from https://www.evidencepositioningsystem.com/. (113 articles and/or guidelines reviewed)

BlueCross BlueShield Association. Evidence Positioning System. (8:2018). Invasive prenatal (fetal) diagnostic testing (2.04.116). Retrieved August 16, 2019 from https://www.evidencepositioningsystem.com/. (16 articles and/or guidelines reviewed)

Hillman, S.C., McMullan, D.J., Hall, G., Togneri, F.S., James, N., et al. (2013). Use of prenatal chromosomal microarray: prospective cohort study and systematic review and meta-analysis. Ultrasound in Obstetrics and Gynecology, 41, 610-620.  (Level 1 evidence)

Lovrecic, L., Remec, Z., Volk, M., Rudolf, G., Writzl, K., & Peterlin, B. (2016). Clinical utility of array comparative genomic hybridization in prenatal setting. BMC Medical Genetics, 17, 81. (Level 4 evidence)

National Institute for Health and Care Excellence. (2017, December). Autism spectrum disorder in under 19s: recognition, referral and diagnosis. Retrieved August 27, 2018 from www.nice.org.uk. 

Redin,C., GĂ©rard, B., Lauer, J., Herenger, Y., Muller, J., Quartier, A., et al. (2014). Efficient strategy for the molecular diagnosis of intellectual disability using targeted high-throughput sequencing. Journal of Medical Genetics, 51, 724-736. (Level 3 evidence)

Technology Evaluation Center. (2015, August). Special report: Chromosomal microarray for the genetic evaluation of patients with global developmental delay, intellectual disability, and autism spectrum disorder. Retrieved September 22, 2015 from http://www.bcbs.com.

Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 23 Mandated Insurer or Plan Options: 56-7-2367. Autism spectrum disorders. Retrieved August 19, 2019 from http://www.lexisnexis.com.

ORIGINAL EFFECTIVE DATE:  1/8/2011

MOST RECENT REVIEW DATE:  9/26/2019

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment. 

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