Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a nine-year-old female enrollee has requested reimbursement for the gene panel testing (CPT 81225 - cyp2c19; CPT 81226 - cyp2d6; CPT 81227 - cyp2c9; CPT 81291 - MTHFR; CPT 81404 - molecular pathology procedure level 2; CPT 81479 - cyp1a2, cyp2b6, htr2a, slc6a4, ugt2b15 and ugt1a4; and CPT 81599 - line 8: ADHD incremental, COMT, ADRA2A) for evaluation of the enrollees attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that The documentation provided does not indicate specific prior medication doses used, length of medication trials or combinations of medications tried and failed. The documentation provided does not indicate that the patient has failed medication trials of adequate dose and duration or that the patient has tried or failed evidence based psychotherapy trials. According to the testing results, the patient is a candidate for several medications. However, none of the listed medications are routinely used for the treatment of ADHD. Moreover, there is no documentation that the patient has been treated with cognitive behavioral therapy (CBT) or behavioral management for ADHD. Research has indicated that CBT and behavior management are effective in patients with ADHD. Furthermore, the current evidence base does not support the use of pharmacogenomic testing in this clinical setting. Accordingly, the gene panel testing (CPT 81225 - cyp2c19; CPT 81226 - cyp2d6; CPT 81227 - cyp2c9; CPT 81291 - mthfr; CPT 81404 - molecular pathology procedure level 2; CPT 81479 - cyp1a2, cyp2b6, htr2a, slc6a4, ugt2b15 and ugt1a4; and CPT 81599 - line 8: ADHD incremental, COMT, ADRA2A) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the gene panel testing (CPT 81225 - cyp2c19; CPT 81226 - cyp2d6; CPT 81227 - cyp2c9; CPT 81291 - mthfr; CPT 81404 - molecular pathology procedure level 2; CPT 81479 - cyp1a2, cyp2b6, htr2a, slc6a4, ugt2b15 and ugt1a4; and CPT 81599 - line 8: ADHD incremental, COMT, ADRA2A) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. One Reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing.  One Reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.