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Blue Shield of CaliforniaAll Plans · Coverage · Genetic Testing · CA · Genetics, Pediatrics, Neurology +1 moreMedium impact

Genetic Testing for FMR1 Variants (Including Fragile X Syndrome) (2.04.83)

Effective date
Apr 1, 2026
Identified
Nov 1, 2025

Summary

Genetic testing for FMR1 variants may be considered medically necessary for individuals with characteristics of fragile X syndrome or a fragile X-associated disorder, including individuals with intellectual disability, developmental delay, or autism spectrum disorder, women with primary ovarian insufficiency under age 40 when fragile X-associated primary ovarian insufficiency is suspected, and individuals with neurologic symptoms consistent with fragile X-associated tremor or ataxia syndrome. It may also be considered medically necessary for individuals with a personal or family history of fragile X syndrome who are seeking reproductive counseling, including those with a family history of fragile X syndrome or undiagnosed intellectual disability, affected individuals or relatives with a positive cytogenetic fragile X test seeking carrier status information, and prenatal testing of fetuses of known carrier mothers. Genetic testing for FMR1 variants is investigational for all other uses.

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What to do

Action · 2 steps
01Already effective April 1, 2026: Please provide the following documentation for clinical review: clinical findings (pertinent symptoms and duration), comorbidities, family history if applicable, reason for the test, past and present diagnostic testing and results, laboratory results, consultation reports when applicable, and other pertinent multidisciplinary notes or reports when applicable.
02After service, also include the results or reports of tests performed and the procedure report.

Codes mentioned

812438124496041

Original notice

Genetic Testing for FMR1 Variants (Including Fragile X Syndrome) (2.04.83)
blueshieldca.com · Always check the source before changing claims.
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