Medical Policy Updates

Medical Policy:  V.62 Specialty Testing:   Multisystem Genetic Conditions

Effective Date:  01/01/2027
Preauthorization Required: YES 

Additional Criteria Added:

Standard Exome or Genome Sequencing

4. Standard exome sequencing after standard genome sequencing is considered investigational.
5. Standard exome sequencing with reflex to standard genome sequencing is considered investigational.
6. Standard genome sequencing is considered investigational if completed less than one year following standard exome sequencing.
7. Standard exome sequencing or standard genome sequencing is considered investigational for all other indications, including screening asymptomatic/healthy individuals for genetic disorders.

Medical Policy:  III.240 Apheresis

Effective Date:  01/01/2027
Preauthorization Required: YES  

LB 762 requires insured and non-ERISA self-funded plans to cover the “treatment of pediatric autoimmune neuropsychiatric disorder associated with a Group A streptococcal infection and pediatric acute-onset neuropsychiatric syndrome.

Those required treatments shall be recommended by the patient's licensed physician and shall include, but not be limited to, antibiotics, medication and behavioral therapies to manage neuropsychiatric symptoms, plasma exchange, and immunoglobulin. 

1. Initial therapy for plasma apheresis  may be considered medically necessary for PANDAS or PANS when the following criteria are met:
   1. Documentation of abrupt, dramatic onset (within less than one month) of obsessive-compulsive disorder or severely restricted food intake: AND
   2. Documentation that at least two additional neuropsychiatric symptoms were present simultaneously and demonstrated a similarly acute and severe onset, with symptoms represented across at least two of the following categories:
      1. Anxiety
      2. Rapid mood changes and/or depression
      3. Irritability, aggression, and/or severely oppositional behaviors
      4. Developmental  regression
      5. Deterioration in school performance (related to attention deficit/hyperactivity disorder (ADHD) like symptoms, memory deficits, cognitive changes)
      6. Sensory or motor impairments 
      7. Somatic manifestations (sleep disturbance, enuresis, urinary frequency)
         AND
   3. Onset of symptoms occurs before the age of 19 years old AND
   4. Documentation that other causes of symptoms have been ruled out AND
   5. Submission of a documented objective baseline assessment of symptom severity using a validated measurement tool (e.g., CY-BOCS, CGI-S, or Parent-Rated PANS Scale) AND
   6. For members with suspected PANDAS, documentation that the abrupt onset or worsening of symptoms followed a documented Group A streptococcal infection
2. Continued plasma apheresis therapy beyond age 19 for individuals already being treated for PANDAS or PANS may be considered medically necessary when the following is met:
   1. The individual has demonstrated a clinically meaningful response to plasma pheresis, as evidenced by improvement in neuropsychiatric symptoms, functional status, or both; AND
   2. The treating provider documents that discontinuation of initial therapy is likely to result in symptom recurrence, functional decline, or clinical deterioration;