PVS1 null variant (nonsense, frameshift, canonical ±1 or 2 splice sites, initiation codon, single or multiexon deletion) in a gene where LOF is a known mechanism of disease

Caveats:

• Beware of genes where LOF is not a known disease mechanism (e.g., GFAP, MYH7)
• Use caution interpreting LOF variants at the extreme 3′ end of a gene
• Use caution with splice variants that are predicted to lead to exon skipping but leave the remainder of the protein intact
• Use caution in the presence of multiple transcripts

BA1 Allele frequency is >5% in Exome Sequencing Project, 1000 Genomes Project, or Exome Aggregation Consortium

PS1 Same amino acid change as a previously established pathogenic variant regardless of nucleotide change

Example: Val→Leu caused by either G>C or G>T in the same codon

Caveat: Beware of changes that impact splicing rather than at the amino acid/protein level

BS1 Allele frequency is greater than expected for disorder

PS2 De novo (both maternity and paternity confirmed) in a patient with the disease and no family history

Note: Confirmation of paternity only is insufficient. Egg donation, surrogate motherhood, errors in embryo transfer, and so on, can contribute to nonmaternity.

BS2 Observed in a healthy adult individual for a recessive (homozygous), dominant (heterozygous), or X-linked (hemizygous) disorder, with full penetrance expected at an early age

PS3 Well-established in vitro or in vivo functional studies supportive of a damaging effect on the gene or gene product

Note: Functional studies that have been validated and shown to be reproducible and robust in a clinical diagnostic laboratory setting are considered the most well established.

BS3 Well-established in vitro or in vivo functional studies show no damaging effect on protein function or splicing

PS4 The prevalence of the variant in affected individuals is significantly increased compared with the prevalence in controls

Note 1: Relative risk or OR, as obtained from case–control studies, is >5.0, and the confidence interval around the estimate of relative risk or OR does not include 1.0. See the article for detailed guidance.

Note 2: In instances of very rare variants where case–control studies may not reach statistical significance, the prior observation of the variant in multiple unrelated patients with the same phenotype, and its absence in controls, may be used as moderate level of evidence.

BS4 Lack of segregation in affected members of a family

Caveat: The presence of phenocopies for common phenotypes (i.e., cancer, epilepsy) can mimic lack of segregation among affected individuals. Also, families may have more than one pathogenic variant contributing to an autosomal dominant disorder, further confounding an apparent lack of segregation.

PM1 Located in a mutational hot spot and/or critical and well-established functional domain (e.g., active site of an enzyme) without benign variation

BP1 Missense variant in a gene for which primarily truncating variants are known to cause disease

PM2 Absent from controls (or at extremely low frequency if recessive) in Exome Sequencing Project, 1000 Genomes Project, or Exome Aggregation Consortium

BP2 Observed in trans with a pathogenic variant for a fully penetrant dominant gene/disorder or observed in cis with a pathogenic variant in any inheritance pattern

PM3 For recessive disorders, detected in trans with a pathogenic variant

Note: This requires testing of parents (or offspring) to determine phase

BP3 In-frame deletions/insertions in a repetitive region without a known function

PM4 Protein length changes as a result of in-frame deletions/insertions in a nonrepeat region or stop-loss variants

BP4 Multiple lines of computational evidence suggest no impact on gene or gene product (conservation, evolutionary, splicing impact, etc.)

Caveat: Because many in silico algorithms use the same or very similar input for their predictions, each algorithm cannot be counted as an independent criterion. BP4 can be used only once in any evaluation of a variant.

PM5 Novel missense change at an amino acid residue where a different missense change determined to be pathogenic has been seen before

Example: Arg156His is pathogenic; now you observe Arg156Cys

Caveat: Beware of changes that impact splicing rather than at the amino acid/protein level.

BP5 Variant found in a case with an alternate molecular basis for disease

PM6 Assumed de novo, but without confirmation of paternity and maternity

BP6 Reputable source recently reports variant as benign, but the evidence is not available to the laboratory to perform an independent evaluation

PP1 Cosegregation with disease in multiple affected family members in a gene definitively known to cause the disease

Note: May be used as stronger evidence with increasing segregation data

BP7 A synonymous (silent) variant for which splicing prediction algorithms predict no impact to the splice consensus sequence nor the creation of a new splice site AND the nucleotide is not highly conserved

PP2 Missense variant in a gene that has a low rate of benign missense variation and in which missense variants are a common mechanism of disease

PP3 Multiple lines of computational evidence support a deleterious effect on the gene or gene product (conservation, evolutionary, splicing impact, etc.)

Caveat: Because many in silico algorithms use the same or very similar input for their predictions, each algorithm should not be counted as an independent criterion. PP3 can be used only once in any evaluation of a variant.

PP4 Patient’s phenotype or family history is highly specific for a disease with a single genetic etiology

PP5 Reputable source recently reports variant as pathogenic, but the evidence is not available to the laboratory to perform an independent evaluation