Expanded Coverage for Fragile X Syndrome - Prenatal Carrier Testing

Date Issued: 11/11/2014

Prenatal Testing:

Effective November 1, 2014 prenatal carrier testing for fragile X syndrome is covered for Medicaid Managed Care (MMC) and Family Health Plus (FHPlus) members when one or more of the following criteria are met:

  • There is a personal or family history of fragile X tremor/ataxia syndrome, autism spectrum disorder or unexplained mental retardation in a 1st, 2nd or 3rd degree* relative of either parent.
  • The patient has elevated Follicle Stimulating Hormone (FSH) levels and is less than 40 years of age or has premature ovarian failure with no known cause.
  • The patient or a 1st or 2nd degree* female relative of either parent is a confirmed carrier.

*1st degree relatives: Parents, children, siblings
  2nd degree relatives: Grandparents, aunts and uncles, nieces and nephews,
  and grandchildren
  3rd degree relatives: First cousins

Codes:


81243 FMR1 (fragile X mental retardation 1) (e.g., fragile X mental retardation) gene analysis; evaluation to detect abnormal (e.g., expanded) alleles

81244 FMR1 (fragile X mental retardation 1) (e.g., fragile X mental retardation) gene analysis; characterization of alleles (e.g., expanded size and methylation status)

EmblemHealth maintains a contract with Quest Diagnostics Inc. to provide outpatient clinical services to our members. In order to ensure that members receive the highest level of plan benefit, laboratory specimens must be referred to Quest Diagnostics.