Effective for dates of service on or after May 1, 2021, the Department of Health Care Services (DHCS) has updated CPT® code 81434 (hereditary retinal disorders [e.g., retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy], genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR and USH2A) from being a non-benefit to a benefit.
A Treatment Authorization Request (TAR) for code 81434 requires documentation of the following criteria:
- Patient has a clinical diagnosis of retinal dystrophy (retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy) and
- The decision for gene therapy is contingent on the test results
CPT code 81434 has a frequency limit of once in a lifetime and the allowable modifiers are 33, 90 and 99. The age and gender coverage are retained.