Does Q79.69 require prior authorization?

No, Q79.69 does not require prior authorization (high confidence). Code is covered without prior authorization.

`Q79.69`, Other Ehlers-Danlos syndromes

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Test panel must include at minimum the COL5A1 and COL5A2 genes.
Clinical evaluation findings and family history documenting features consistent with hEDS (since hEDS diagnosis is clinical and genetic testing is not appropriate for hEDS).
Refer to policy section for documentation required when evaluating non-hEDS EDS subtypes (if pursuing genetic evaluation for other EDS types).
Submission of the pertinent ICD-10-CM diagnosis code(s) supporting testing (examples: I71.00-I71.9 for TAAD; Q87.5 for Loeys‑Dietz; M35.7, Q79.61, Q79.63, Q79.69 for Ehlers‑Danlos).

Myopathic EDS with clinical features suggestive of the disorder (COL12A1).
Periodontal EDS with clinical features suggestive of the disorder (C1R, C1S).
Spondylodysplastic EDS with clinical features suggestive of the disorder (B4GALT7, B3GALT6, SLC39A13).
Genetic testing for hereditary connective tissue disorders when clinical features suggest a HCTD (e.g., generalized joint hypermobility, thoracic aortic aneurysm or dissection).
Genetic testing when results are expected to change clinical management, such as initiation or modification of aortic surveillance, surgical planning for the aorta, or multisystem surveillance for syndromic conditions with risk of thoracic aortic aneurysm/dissection.
Genetic testing when clinical and family history alone are insufficient to reliably establish a diagnosis of a hereditary connective tissue disorder.

AMBETTER-CG-Aorto-2025.1, Concert Genetic Testing: Aortopathies and Connective Tissue Disorders

AMBETTER-CP.MP.99, Wheelchair Seating

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