Medical_Policy

Highmark Commercial Medical Policy - Pennsylvania

Medical Policy:	L-196-002
Topic:	Neurogenic Muscle Weakness, Ataxia, and Retinitis Pigmentosa (NARP)
Section:	Laboratory
Effective Date:	November 13, 2017
Issue Date:	November 13, 2017
Last Reviewed:	March 2017

NARP is a multisystem mitochondrial disease characterized by proximal neurogenic muscle weakness with sensory neuropathy, ataxia, learning difficulties, and pigmentary retinopathy. Most cases present in childhood with ataxia and learning difficulties. Seizures may also be present.

NARP is caused by mutations in the mitochondrial DNA (mtDNA) and follows maternal inheritance. This means that a female who carries the mtDNA mutation at high mutation load will typically pass it on to all of her children. A male who carries the mtDNA mutation cannot pass it on to his children.

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.

Known NARP Familial Mutation Testing may be considered medically necessary when the following criteria have been met:

Genetic Counseling:
- Pre and post-test counseling by an appropriate provider; and
Previous Genetic Testing:
- No previous genetic testing in the individual for NARP*; and
- NARP pathogenic variant identified in matrilineal relative; and
Predictive Testing for Asymptomatic Individual:
- 18 years of age or older; or
- Under the age of 18 years; and
  - Screening for learning disabilities, retinitis pigmentosa, and/or ataxia is being considered; or
Diagnostic Testing for Symptomatic Individual:
- Clinical exam and/or biochemical testing suggestive, but not confirmatory, of a diagnosis of NARP.

NARP Targeted Mutation Analysis may be considered medically necessary when ALL of the following criteria have been met:

Genetic Counseling:
- Pre and post-test counseling by an appropriate provider; and
Previous Testing:
- No previous genetic testing for NARP*; and
- No known NARP pathogenic variants in the family; and
Diagnostic Testing for Symptomatic Individuals:
- Clinical exam and/or biochemical testing suggestive, but not confirmatory, of a diagnosis of NARP; and
- Genetic testing is needed to confirm the diagnosis.

Whole mtDNA Sequencing may be considered medically necessary when ALL of the following criteria have been met:

Genetic Counseling:
- Pre and post-test counseling by an appropriate provider; and
Criteria for NARP targeted mutation analysis is met; and
No pathogenic variants identified in the NARP targeted mutation analysis; and
Paternal transmission has been ruled out.

*Exceptions may be considered if technical advances in testing demonstrate significant advantages that would support a medical need to retest.

Procedure Codes

81400, 81406

Professional Statements and Societal Positions

Guidelines and Evidence

No specific evidence-based U.S. testing guidelines were identified.
Case reports and a limited number of case series are the primary evidence base available for the diagnosis of mitochondrial disease
The Mitochondrial Medicine Society developed consensus recommendations using the Delphi method and published them in 2015.
- Recommendations for DNA testing:
  - “Massively parallel sequencing/NGS of the mtDNA genome is the preferred methodology when testing mtDNA and should be performed in cases of suspected mitochondrial disease instead of testing for a limited number of pathogenic point mutations.
  - Patients with a strong likelihood of mitochondrial disease because of a mtDNA mutation and negative testing in blood, should have mtDNA assessed in another tissue to avoid the possibility of missing tissue-specific mutations or low levels of heteroplasmy in blood; tissue-based testing also helps assess the risk of other organ involvement and heterogeneity in family members and to guide genetic counseling.
  - Heteroplasmy analysis in urine can selectively be more informative and accurate than testing in blood alone, especially in cases of MELAS due to the common m.3243 A>G mutation.
  - When considering nuclear gene testing in patients with likely primary mitochondrial disease, NGS methodologies providing complete coverage of known mitochondrial disease gene is preferred. Single-gene testing should usually be avoided because mutations in different genes can produce the same phenotype. If no mutation is identified via known NGS panels, then whole exome sequencing should be considered.
A workshop of the National Institute of Neurological Disorders and Stroke (2008) summarizes:
- "The diagnosis of mitochondrial diseases is complicated by their heterogeneous presentations and by the lack of screening procedures or diagnostic biomarkers that are both sensitive and specific. The workshop panelists explained that diagnosis is often a lengthy process beginning with a general clinical evaluation followed by metabolic screening and imaging and finally by genetic tests and more invasive biochemical and histological analyses. The identification of known mitochondrial mutations in tissue has greatly aided diagnosis. However, even when clinical features and family history strongly suggest mitochondrial disease, the underlying genetic mutation can elude detection, and there is no current screening procedure that would be practical for all cases of suspected mitochondrial disease."
The Clinical Molecular Genetics Society (CMGS) of the United Kingdom (2008) practice-based guidelines for the molecular diagnosis of mitochondrial disease state that: "For routine referrals for NARP, presence of T8993G and T8993C mutations should be investigated."
The European Federation of Neurological Sciences (2009) evidence-based molecular diagnostic guidelines state: "If the phenotype suggests syndromic mitochondrial disease due to mtDNA point mutations (MELAS, MERRF, NARP, LHON) DNA-microarrays using allele-specific oligonucleotide hybridisation, real-time-PCR or single-gene sequencing are indicated."

Place of Service: Outpatient

NARP 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.

Links

Link to Provider Resource Center for the Medical Policy Update

05/2017, REMINDER: Molecular and Genomic Testing

Link to References

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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