Does Not Apply to Commercial Genetic Testing Program effective 6/1/2018
DESCRIPTION
CHARGE syndrome is a rare genetic condition associated with multiple congenital anomalies. The letters of CHARGE syndrome correspond to clinical features: C = ocular Coloboma, H = Heart defect, A = Atresia choanae, R = Retarded growth and development, G = Genital hypoplasia and E = Ear anomalies/deafness. There are other malformations also common in this condition. In particular, hypoplasia of the semi-circular canals has emerged as a frequent and distinctive CHARGE malformation. The condition is caused by mutations of the CHD7 gene on chromosome 8q12.1. CHD7 is the only gene currently known to be associated with CHARGE syndrome.
In many individuals, the diagnosis can be made based on clinical findings. Since the phenotype of the disease is highly variable, some individuals do not fulfill all the criteria for diagnosis by clinical findings. Major characteristics include ocular coloboma, choanal atresia or stenosis, cranial nerve abnormality, ear anomalies or deafness. Minor characteristics include genital hypoplasia, hypogonadotrophic hypogonadism, developmental delays, cardiac malformations, short stature, cleft lip and/or cleft palate, tracheoesophageal fistula, and distinctive CHARGE facial appearance, which consist of a prominent forehead and a prominent nasal bridge. Other, less frequent manifestations include kidney malformations, immunodeficiency, various limb abnormalities, scoliosis, dental problems, omphalocele, brain malformations, attention deficit hyperactivity disorder (ADHD), and various behavioral problems.
Most instances of CHARGE syndrome are sporadic events in a family and appear to be caused by de novo CHD7 mutations, but on rare occasions CHARGE can be inherited as an autosomal dominant condition. Recurrence in siblings because of germline mosaicism has also been reported. The prevalence of CHARGE syndrome is estimated at 1 in 8,500 live births.
POLICY
Genetic testing for CHARGE syndrome is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Pre- and post-genetic counseling as an adjunct to genetic testing is considered medically necessary.
Genetic testing for CHARGE syndrome in all other situations is considered investigational.
MEDICAL APPROPRIATENESS
Genetic testing is considered medically appropriate if ALL the following criteria are met:
To confirm a diagnosis in individuals with signs/symptoms of CHARGE syndrome
Definitive diagnosis cannot be made with clinical criteria
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
ADDITIONAL INFORMATION
A diagnosis of definite CHARGE syndrome can be made clinically in individuals with all four major characteristics or three major and three minor characteristics. In individuals without the classical clinical criteria to diagnose CHARGE, in those with a milder phenotype, and/or in those with features that overlap with and cannot be distinguished from other syndromes, genetic testing may provide a definitive diagnosis.
SOURCES
BlueCross BlueShield Association. Evidence Positioning System. (3:2023). Genetic testing for CHARGE syndrome (2.04.106). Retrieved September 14, 2023 from www.bcbsaoca.com/eps/. (16 articles and/or guidelines reviewed)
CMS.gov: Centers for Medicare & Medicaid Services. Palmetto GBA. (2019, October). Local Coverage Article: Billing and Coding: MolDX: CHD7 gene analysis A53565. Retrieved June 11, 2021 from https://www.cms.gov.
Legendre, M., Abadie, V., Attié-Bitach, T., Philip, N., Busa, T., Bonneau, D., et al. Phenotype and genotype analysis of a French cohort of 119 patients with CHARGE syndrome. American Journal of Medical Genetics, 175 (4), 417-430. Abstract retrieved November 22, 2019 from PubMed database.
van Ravenswaaij-Arts, C.M., Blake, K., Hoefsloot, L., & Verloes, A. (2015). Clinical utility gene card for: CHARGE syndrome - update 2015. European Journal of Human Genetics, 23 (11), doi:10.1038/ejhg.2015.15 (Level 2 evidence)
ORIGINAL EFFECTIVE DATE: 2/9/2014
MOST RECENT REVIEW DATE: 10/12/2023
ID_BA
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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