Highmark Commercial Medical Policy - Pennsylvania


 
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Medical Policy: L-162-006
Topic: Dentatorubral-Pallidoluysian Atrophy Testing
Section: Laboratory
Effective Date: July 1, 2018
Issue Date: July 2, 2018
Last Reviewed: March 2018

Dentatorubral-pallidoluysian atrophy (DRPLA) is a progressive neurologic disorder. Age of onset ranges from one year of age to 72 years of age, with the mean age being 31.5 years of age. The diagnosis of DRPLA is based on presenting findings, family history, and the results of molecular genetic testing demonstrating an expansion of the CAG trinucleotide/polyglutamine tract in ATN1.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

DRPLA testing may be considered medically necessary for the following indications:

  • Pre and post-test genetic counseling by an appropriate provider; and
  • Previous Testing:
    • No previous ATN1 testing for DRPLA; and
  • Diagnostic Testing for Symptomatic Individuals:
    • Less than 20 years of age and at least 2 or more of the following:
      • Ataxia; or
      • Myoclonus; or 
      • Seizures; or
      • Progressive intellectual deterioration/behavior changes; or
      • Affected 1st degree biologic relative or Japanese/Haw River descent; or
    • Greater than or equal to 20 years of age and at least 2 or more of the following:
      • Ataxia; or 
      • Choreoathetosis; or 
      • Affected 1st degree biologic relative or Japanese/Haw River descent; or
  • Predisposition Testing for Presymptomatic/Asymptomatic Individuals:
    • ATN1 CAG trinucleotide expansion detected in 1st degree biologic relative; or
    • Suspected DRPLA in a deceased 1st, 2nd, or 3rd degree biologic relative who was not genetically diagnosed.
Procedure Codes
81401

Professional Statements and Societal Positions

No U.S. guidelines exist for genetic testing for DRPLA.

A 2010 expert-authored review states:

  • "The diagnosis of dentatorubral-pallidoluysian atrophy (DRPLA) is established in individuals with disease-causing CAG trinucleotide expansions in ATN1 (DRPLA) who are:
    • Under age 20 years and have ataxia, myoclonus, seizures, and progressive intellectual deterioration;
    • Over age 20 years and have ataxia, choreoathetosis, dementia, and psychiatric disturbance."
  • "Most individuals diagnosed with DRPLA have an affected parent. It is appropriate to evaluate both parents of an affected individual with molecular genetic testing even if they are asymptomatic."
  • "Testing of asymptomatic at-risk adults for DRPLA in the presence of nonspecific or equivocal symptoms is predictive testing, not diagnostic testing. When testing at-risk individuals for DRPLA, it is helpful to test for the CAG expansion in an affected family member to confirm the molecular diagnosis in the family."
  • "At-risk asymptomatic adult family members may seek testing in order to make personal decisions regarding reproduction, financial matters, and career planning. Others may have different motivations including simply the "need to know." Testing of asymptomatic at-risk adult family members usually involves pre-test interviews in which the motives for requesting the test, the individual's knowledge of DRPLA, the possible impact of positive and negative test results, and neurologic status are assessed."
  • "Requests from parents for testing of asymptomatic at-risk individuals during childhood require sensitive and understanding counseling. Consensus holds that individuals under age 18 at risk for adult-onset disorders should not have testing in the absence of symptoms."
  • "If the disease-causing mutation has been identified in the family, prenatal diagnosis for pregnancies at increased risk is possible by analysis of DNA extracted from fetal cells obtained by amniocentesis (usually performed at ~15-18 weeks’ gestation) or chorionic villus sampling (usually performed at ~10-12 weeks’ gestation)."

Place of Service: Outpatient

DRPLA testing is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

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