Cpt Code 81299 Case Study

The reviewer in this case has been asked to address the following concerns related to this member:

1. Is the genetic testing [CPT code 812929 – First Step Dx Plus Testing] that was performed on 02/29/2016 considered experimental and/or investigational? Please explain.

2. Was the genetic testing [CPT code 812929 – First Step Dx Plus Testing], which was performed on 02/29/2016 medically necessary for the treatment of this member’s condition?

3. Is the expected benefit of the recommended or requested health care service or treatment more likely than not to be beneficial to the claimant than any available standard health care service or treatment?

4. Are the adverse risks of the recommended or requested health care service or treatment

In this instance, it appears that this testing was the most appropriate level of services, is likely to improve clinical outcome, and is recognized and generally accepted by the medical profession for the evaluation of this disease.

Therefore, based on the clinical information provided for review and the current peer-reviewed medical literature, the genetic testing [CPT code 812929 – First Step Dx Plus Testing] that was performed on 02/29/2016 is not considered experimental and/or investigational.

Based on the clinical information provided for review, the current peer-reviewed medical literature and the plan criteria, the genetic testing [CPT code 812929 – First Step Dx Plus Testing], which was performed on 02/29/2016 is medically necessary for the treatment of this member’s