Coverage of Carrier Screening

This message is regarding genetic tests used to determine carrier status for cystic fibrosis (CF), Fragile X, and spinal muscular atrophy (SMA). Consistent with the recommendations set forth by ACMG and ACOG, OHCA considers CF carrier screening using the common mutation panel (CPT code 81220) to be medically necessary once in a lifetime for women of reproductive age and the partners of those that test positive.  Expanded mutation panels beyond those recommended by ACMG/ACOG are not considered medically necessary and will be reimbursed at a rate that is based on the common variant panel alone. OHCA does not consider other carrier screening in the general population to be medically necessary.  In particular, carrier screening for Fragile X (CPT code 81243) and SMA (CPT code 81401) are not considered medically necessary in the absence of a family history suggestive of those conditions.  This is consistent with the ACOG and ACMG recommendations for Fragile X carrier screening and the ACOG recommendations for SMA carrier screening.