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Mutations in the DMD gene, which encodes the protein dystrophin, may result in a spectrum of X-linked muscle diseases. The severe end of the spectrum includes the progressive muscle diseases Duchenne and Becker muscular dystrophy and dilated cardiomyopathy. Genetic testing can confirm a diagnosis of a dystrophinopathy and distinguish the less and more severe forms, as well as identify female carriers at risk.
The dystrophinopathies include a spectrum of muscle diseases The mild end of the spectrum includes asymptomatic increases in serum concentration of creatine phosphokinase and clinical symptoms such as muscle cramps with myoglobinuria and/or isolated quadriceps myopathy. The severe end of the spectrum includes progressive muscle diseases that lead to substantial morbidity and mortality. When skeletal muscle is primarily affected, they are classified as Duchenne or Becker muscular dystrophy and when the heart is primarily affected, as DMD-associated dilated cardiomyopathy (left ventricular dilation and heart failure).
Duchenne Muscular Dystrophy
Becker Muscular Dystrophy
The dystrophinopathies are X-linked recessive and penetrance is complete in males. The gene that codes for dystrophin is the largest known human gene. A molecular confirmation of DMD and BMD is achieved by confirming the presence of a pathogenic variant in this gene by a number of available assays. The large size of the dystrophin gene results in a complex mutational spectrum with over 5,000 different reported mutations, as well as a high spontaneous mutation rate.
Treatment of Duchenne Muscular Dystrophy
New therapeutic trials require accurate diagnoses of these disorders, especially when the therapy is targeted toward specific mutations. Several of these therapies are currently undergoing clinical trials with two of the most promising being anti-sense oligonucleotide induced exon-skipping and gene repair and replacement with an adeno-associated viral (AAV) vector. Exon-skipping is a molecular therapy aimed at skipping the transcription of a targeted exon to restore a correct reading frame using antisense oligonucleotides. The result is a DMD protein that is formed without the mutated exon and a normal, non-shifted reading frame. Exon skipping may be able to restore DMD protein function so that the treated patient’s phenotypic expression more closely resembles BMD. Gene transfer using AAV vector therapy involves the transfer of a functional DMD gene to the patient using this nonpathogenic and low immune response vector.
No U.S. Food and Drug Administration (FDA)-cleared genotyping tests were found. Thus, genotyping is offered as a laboratory-developed test. Clinical laboratories may develop and validate tests in-house (“home-brew”) and market them as a laboratory service; such tests must meet the general regulatory standards of the Clinical Laboratory Improvement Act (CLIA). The laboratory offering the service must be licensed by CLIA for high complexity testing.
Genetic testing for DMD gene mutations may be considered medically necessary under the following conditions:
Heterozygous females are at increased risk for cardiomyopathy and need routine cardiac surveillance and treatment.
At-risk females are defined as first- and second-degree female relatives and include the proband’s mother, female siblings of the proband, female offspring of the proband, the proband’s maternal grandmother, maternal aunts, and their offspring.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
07/18/2013: New policy added. Approved by Medical Policy Advisory Committee.
05/01/2014: Policy reviewed; no changes.
08/18/2015: Medical policy revised to add ICD-10 codes.
Blue Cross and Blue Shield Association Policy # 2.04.86
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.