Bio Clinical Databases Acmg Classification

Version Compatibility

Reference examples tested with: requests 2.31+, pandas 2.2+, AutoPVS1 (Xiang 2020), InterVar 2.2+, GeneBe 1.0+ (Stawinski 2024 *Clin Genet*). ACMG/AMP Bayesian point system is Tavtigian 2018 *Genet Med* / 2020 *Hum Mutat*. Pejaver 2022 *AJHG* PP3/BP4 calibrated thresholds. ClinGen Splicing Subgroup 2023 (Walker *AJHG*). v3.2 ACMG SF list (Miller 2023). The ACMG 2.0 framework is in development as of May 2026; not yet published.

Before using code patterns, verify installed versions match. If versions differ:

• Python: pip show <package> then help(module.function) to check signatures
• CLI: <tool> --version

If code throws ImportError, AttributeError, or TypeError, introspect the installed package and adapt the example to match the actual API rather than retrying. VCEP-specific CSpec rules override default ACMG application; the authoritative directory is https://cspec.genome.network/cspec/ui/svi/all.

ACMG/AMP Variant Classification Framework

'Classify this variant per ACMG/AMP' -> Apply 28-criterion framework using Tavtigian point system; gate on ClinGen SVI specifications and VCEP-specific overrides; assign P / LP / VUS / LB / B classification with evidence trail.

• Python (automated): GeneBe API https://api.genebe.net/cloud/api-public/v1/variant
• Python (rule-based): InterVar -> python InterVar.py -i input.vcf -b hg38 --table_annovar table_annovar.pl
• Web tools: VarSome (commercial), Franklin/Genoox (commercial), ClinGen VCI (gold standard for SVI)
• Citation: Richards 2015 *Genet Med* 17:405 (original framework); Tavtigian 2020 *Hum Mutat* 41:1734 (point system)

The Tavtigian Bayesian Point System: The Engine Inside All Modern Classifiers

Richards 2015 specified 28 criteria with strength labels (Supporting / Moderate / Strong / Very Strong); combination rules produced P / LP / VUS / LB / B. Tavtigian 2018/2020 demonstrated this framework is mathematically a Bayesian classifier and proposed the naturally-scaled point system that every modern automated classifier implements:

| Strength | Points | Odds of pathogenicity |

|----------|--------|----------------------|

| Supporting | 1 | 2.08:1 |

| Moderate | 2 | 4.33:1 |

| Strong | 4 | 18.7:1 |

| Very Strong | 8 | 350:1 |

Benign codes are negative-signed. Final classification:

| Sum of points | Category |

|---------------|----------|

| >= 10 | Pathogenic |

| 6-9 | Likely Pathogenic |

| 0-5 | VUS |

| -1 to -6 | Likely Benign |

| <= -7 | Benign |

InterVar / GeneBe / VarSome / Franklin all implement Tavtigian point summation under the hood. Combinations never appearing in the 2015 combining rules (e.g., PVS1_VeryStrong + PM2_Supporting -> LP) emerge naturally from point arithmetic.

PVS1 Decision Tree (Abou Tayoun 2018 *Hum Mutat* 39:1517)

PVS1 is the most consequential code: pathogenic Very Strong (8 points) for predicted loss-of-function in a gene where LoF is established disease mechanism. The 2018 decision tree refined PVS1 from a binary into a graded code based on:

• Variant type: nonsense / frameshift / canonical +-1,2 splice / initiation codon / single-exon deletion / multi-exon deletion.
• NMD prediction: variant in 5'-most exon OR >50bp upstream of last exon-exon junction -> NMD-triggered. Else truncated protein.
• Critical region: removal of >10% of coding sequence OR removal of a critical functional domain.
• Alternative isoform: does the variant affect a transcript expressed in disease-relevant tissue?

Output strengths:

| Output | Original Strength |

|--------|-------------------|

| PVS1_VeryStrong | Strongest (Very Strong) |

| PVS1_Strong | Strong |

| PVS1_Moderate | Moderate |

| PVS1_Supporting | Supporting |

Subsumption rule (Abou Tayoun 2018): PVS1 + PP3 -> only PVS1 counts (PP3 is subsumed). Same for PVS1 + PM4.

>15 VCEP-specific PVS1 trees exist as of 2024 (CDH1, ENIGMA BRCA1/2, FH LDLR/APOB/PCSK9, InSiGHT MMR, RASopathies, hearing loss, hypertrophic cardiomyopathy, Rett/Angelman, etc.). The automated implementation is AutoPVS1 (Xiang 2020).

Pejaver 2022 PP3/BP4 Calibrated Thresholds (the load-bearing 2024+ calibration)

Pejaver 2022 *AJHG* 109:2163 Bayesian-calibrated 13 missense predictors to PP3/BP4 strength levels using ClinVar P/B variants with leave-one-gene-out cross-validation.

| Predictor | BP4_Strong | BP4_Moderate | BP4_Supporting | PP3_Supporting | PP3_Moderate | PP3_Strong | Fails when |

|-----------|-----------|--------------|----------------|----------------|--------------|------------|-----------|

| REVEL | <= 0.003 | <= 0.016 | <= 0.290 | >= 0.644 | >= 0.773 | >= 0.932 | Stacked with BayesDel/VEST4 (training overlap; double-counting) |

| BayesDel (no AF) | <= -0.36 | <= -0.18 | <= -0.08 | >= 0.13 | >= 0.27 | >= 0.50 | Combined with AF-aware variant (use no-AF version with PM2_Supporting) |

| VEST4 | <= 0.302 | <= 0.449 | <= 0.302 | >= 0.764 | >= 0.861 | >= 0.965 | Indels (missense-trained); regulatory variants |

| MutPred2 | (Pejaver 2022) | -- | -- | -- | -- | -- | Genes with sparse MAVE training data |

| AlphaMissense | NOT ClinGen-endorsed | -- | -- | Use as supporting only | -- | NOT ClinGen-endorsed | Developer threshold 0.564 misapplied as PP3 |

The two numbers to memorize: REVEL >= 0.932 = PP3_Strong; REVEL <= 0.290 = BP4_Strong (or <= 0.003 BP4_VeryStrong).

AlphaMissense calibration (Schmidt 2025 *Genet Med* 27:e101339, originally Pejaver et al. bioRxiv 2024.09.17): AlphaMissense reaches PP3_Strong and BP4_Moderate at calibrated thresholds. Critical: the developer-recommended 0.564 threshold is NOT the Pejaver PP3 threshold. ClinGen has NOT endorsed AlphaMissense PP3 strength as of May 2026; treat as supporting evidence only.

Do not stack predictors. REVEL, BayesDel, VEST4 share ClinVar/HGMD training data; using REVEL >= 0.773 AND BayesDel >= 0.27 to claim "two independent moderate hits" is double-counting. Pejaver 2022 explicitly recommends using ONE predictor per variant.

PM2_Supporting (ClinGen SVI 2020)

The original PM2 ("absent from controls") was over-weighted. SVI 2020 downgraded to PM2_Supporting (1 point, not 2). Mechanism: most rare variants are benign. Empirical recalibration showed ~6 variants per gene downgrade from LP to VUS when PM2 -> Supporting. Many 2017-2019 LP curations require re-classification post-SVI 2020 update.

PS3/BS3 Functional Evidence (Brnich 2020 *Genome Med* 12:3)

OddsPath framework; the four-step SOP:

• Define disease mechanism for the gene.
• Evaluate assay class (e.g., MAVE, biochemical, animal model).
• Evaluate specific assay instance (controls, replicate consistency).
• Apply per-variant.

OddsPath calibration mapping to ACMG strengths:

| OddsPath | Pathogenic strength | Benign strength |

|----------|--------------------:|----------------:|

| > 18.7 | Very Strong | n/a |

| 4.3 - 18.7 | Strong | -- |

| 2.1 - 4.3 | Moderate | -- |

| 1.2 - 2.1 | Supporting | (mirror) |

MAVEdb deep-mutational scans with >=11 controls (>=5 P/LP + >=5 B/LB) can yield up to PS3_Strong/BS3_Strong via OddsPath calibration. This is the entry point for MAVE/saturation-mutagenesis evidence into ACMG.

Default-Strong PS3 application is increasingly over-strengthening without OddsPath calibration; ClinGen SVI recommends moving toward PS3_Moderate as default unless OddsPath > 4.3.

ClinGen SVI Splicing Subgroup 2023 (Walker *AJHG* 110:1046)

SpliceAI is the recommended primary splicing tool. Calibrated thresholds:

| SpliceAI DS_max | Strength |

|-----------------|----------|

| >= 0.5 (Jaganathan 2019 default) | Can support PP3_Strong with corroborating evidence |

| >= 0.20 | Minimum threshold for ANY splicing PP3 |

| < 0.1 | BP4_Moderate (weaker than missense BP4 because absence of predicted aberrant splicing is less informative) |

SpliceVault / 300K-RNA (Dawes 2023 *Nat Genet* 55:324): does NOT predict whether a variant is splice-altering; predicts WHAT the aberrant transcript will be (which exon skips, which cryptic site activates). 96% sensitivity for exon-skipping; 86% for cryptic site activation in 140 clinical RNA-tested cases. Critical for PVS1 application to splice variants because PVS1 depends on whether the aberrant transcript triggers NMD.

Pangolin (Zeng 2022 *Genome Biol* 23:103): SpliceAI improvement for cryptic donor sites; not yet ClinGen-endorsed but increasingly used as tiebreaker.

BS1 / BA1 (Whiffin Max-Credible-AF)

BA1 default: AF > 5% in non-bottleneck group per ClinGen SVI; VCEP-specific overrides (Hearing Loss VCEP uses 0.5% AR).

BS1 gene-specific: (prevalence x heterogeneity x allelic-contribution) / (penetrance x 2) from Whiffin 2017 *Genet Med* 19:1151. Compare against gnomAD grpmax_faf95.

See clinical-databases/gnomad-frequencies for FAF95 details.

ClinGen VCEP CSpec Hierarchy

| Layer | Authority | Application |

|-------|-----------|-------------|

| Generic ACMG/AMP 2015 | Richards 2015 | Default fallback |

| ClinGen SVI specifications | SVI Working Group | Overrides generic for all genes (PM2 -> Supporting; AutoPVS1 trees; etc.) |

| VCEP-specific CSpec | Gene/disease-specific expert panel | Overrides SVI for that gene-disease |

ClinGen VCEP CSpec authoritative registry: https://cspec.genome.network/cspec/ui/svi/all. ~80-90 VCEPs as of 2025. Examples:

• Hearing Loss VCEP: PM2 -> supporting default; PS3 thresholds upgraded for OTOF; BA1 lowered to 0.5% AR.
• ENIGMA BRCA1/2 VCEP: gene-specific PVS1 trees with NMD escape rules; PS4 case-control thresholds.
• Inherited Cardiac Conditions VCEP: gene-specific PS4 (5+ unrelated probands for PS4_Supporting).

Apply VCEP CSpec when one exists. Generic ACMG with no VCEP awareness is unreliable for many genes.

Cancer Somatic Framework (Li 2017 *J Mol Diagn* 19:4)

AMP/ASCO/CAP somatic variant interpretation; four tiers:

| Tier | Definition | Action |

|------|-----------|--------|

| Tier I-A | FDA-approved drug for same tumor type with this biomarker | On-label therapy |

| Tier I-B | Professional guidelines (NCCN, ESMO) | Standard-of-care |

| Tier II-C | FDA drug in different tumor type (off-label) | Basket trials |

| Tier II-D | Preclinical / investigational | Research |

| Tier III | VUS-somatic | Watch list |

| Tier IV | Benign-somatic | Filter out |

Knowledgebases: OncoKB (MSKCC; Chakravarty 2017), CIViC (Griffith 2017 *Nat Genet* 49:170), CGI (Tamborero 2018), JAX-CKB, COSMIC. OncoKB Levels (1-4 therapeutic) map to AMP tiers loosely.

The Variant Interpretation for Cancer Consortium (VICC) Meta-Knowledgebase standards (2024-2025) harmonize across knowledgebases. ClinGen Somatic VCEPs are emerging (started 2022).

Decision Tree by Variant Type

| Variant type | Recommended workflow |

|--------------|----------------------|

| Predicted LoF in known LoF-mechanism gene | AutoPVS1 decision tree -> PVS1_VeryStrong/Strong/Moderate/Supporting; check VCEP-specific PVS1 |

| Missense in known missense-pathogenic gene | Apply Pejaver 2022 PP3/BP4 calibrated thresholds; ONE predictor only |

| Splice variant | SpliceAI DS_max + SpliceVault for aberrant-transcript prediction; PP3_Strong if >=0.5 with corroborating evidence |

| Synonymous | SpliceAI for cryptic splice effect; synVep / PrimateAI synonymous extension |

| Variant in ACMG SF v3.2 gene | Apply full classification; flag P/LP for opt-in disclosure |

| Cancer somatic variant | AMP/ASCO/CAP 2017 Tier I-IV; cross-check OncoKB / CIViC |

| Variant in Limited gene-disease validity | ClinGen Strong/Definitive required for clinical action |

| Functional evidence available | Brnich 2020 PS3/BS3 OddsPath framework |

| Family segregation | PP1 / BS4 LOD score per Bayrak-Toydemir 2021 |

| In-trans observations (AR) | PM3 with ClinGen tabular scoring system |

| HGVS-c on alternative transcript | Re-evaluate on MANE Select |

Standard Workflow: ACMG Classification

Goal: Apply ACMG/AMP framework to a candidate variant with proper SVI specifications and VCEP overrides.

Approach: Pull aggregated evidence; apply Pejaver-calibrated in-silico thresholds; check VCEP-specific CSpec; sum Tavtigian points.

import requests
import pandas as pd


# Pejaver 2022 calibrated REVEL thresholds (one-predictor rule applies)
REVEL_THRESHOLDS = {
    'BP4_VeryStrong': (-float('inf'), 0.003),
    'BP4_Strong': (0.003, 0.016),
    'BP4_Moderate': (0.016, 0.290),
    'BP4_Supporting': (0.290, 0.644),
    'PP3_Supporting': (0.644, 0.773),
    'PP3_Moderate': (0.773, 0.932),
    'PP3_Strong': (0.932, float('inf'))
}

# Tavtigian point assignments (Tavtigian 2020 Hum Mutat)
STRENGTH_POINTS = {
    'PVS1_VeryStrong': 8, 'PVS1_Strong': 4, 'PVS1_Moderate': 2, 'PVS1_Supporting': 1,
    'PS1': 4, 'PS2': 4, 'PS3': 4, 'PS3_Moderate': 2, 'PS3_Supporting': 1, 'PS4': 4,
    'PM1': 2, 'PM2_Supporting': 1, 'PM3': 2, 'PM3_Strong': 4, 'PM3_VeryStrong': 8,
    'PM4': 2, 'PM5': 2, 'PM6': 2,
    'PP1': 1, 'PP1_Moderate': 2, 'PP1_Strong': 4,
    'PP2': 1, 'PP3_Supporting': 1, 'PP3_Moderate': 2, 'PP3_Strong': 4, 'PP4': 1, 'PP5': 1,
    # Benign codes (negative)
    'BA1': -100,  # Standalone benign
    'BS1': -4, 'BS2': -4, 'BS3': -4, 'BS3_Moderate': -2, 'BS3_Supporting': -1, 'BS4': -4,
    'BP1': -1, 'BP2': -1, 'BP3': -1,
    'BP4_Supporting': -1, 'BP4_Moderate': -2, 'BP4_Strong': -4, 'BP4_VeryStrong': -8,
    'BP5': -1, 'BP6': -1, 'BP7': -1
}


def classify_revel_pp3_bp4(revel_score):
    '''Map REVEL score to PP3/BP4 strength per Pejaver 2022.'''
    if revel_score is None:
        return None
    for code, (lo, hi) in REVEL_THRESHOLDS.items():
        if lo <= revel_score < hi:
            return code
    return None


def classify_alphamissense_supporting_only(am_score):
    '''AlphaMissense is currently supporting-only; ClinGen has not endorsed PP3 calibration.

    Cheng 2023 developer threshold 0.564 is NOT the Pejaver-style PP3 calibration.
    '''
    if am_score is None:
        return None
    if am_score >= 0.7:
        return 'PP3_Supporting'   # Tentative; ClinGen not endorsed
    if am_score <= 0.2:
        return 'BP4_Supporting'   # Tentative
    return None


def spliceai_to_acmg(ds_max):
    '''Walker 2023 SVI Splicing Subgroup framework.

    SpliceAI >= 0.5 + corroborating evidence -> PP3_Strong (use with caution).
    SpliceAI >= 0.20 -> minimum for ANY splicing PP3.
    SpliceAI < 0.1 -> BP4_Moderate.
    '''
    if ds_max is None:
        return None
    if ds_max >= 0.5:
        return 'PP3_Strong'  # Requires corroborating evidence (RNA assay, conservation)
    if ds_max >= 0.20:
        return 'PP3_Supporting'
    if ds_max < 0.1:
        return 'BP4_Moderate'
    return None


def tavtigian_classify(criteria_assigned):
    '''Sum Tavtigian points and classify P / LP / VUS / LB / B.

    criteria_assigned: list of criterion strings (e.g., ['PVS1_VeryStrong', 'PM2_Supporting'])
    '''
    points = sum(STRENGTH_POINTS.get(c, 0) for c in criteria_assigned)
    if any(c == 'BA1' for c in criteria_assigned):
        return {'classification': 'Benign', 'points': points, 'rationale': 'BA1 standalone'}
    if points >= 10:
        category = 'Pathogenic'
    elif points >= 6:
        category = 'Likely Pathogenic'
    elif points >= 0:
        category = 'VUS'
    elif points >= -6:
        category = 'Likely Benign'
    else:
        category = 'Benign'
    return {'classification': category, 'points': points, 'criteria': criteria_assigned}


def genebe_classify(hgvs):
    '''Query GeneBe API (Stawinski 2024) for automated ACMG classification.

    GeneBe is open-source, Tavtigian-point-system-based, and performs comparably to
    VarSome (which is commercial, 82% ACMG criteria auto-application rate).
    '''
    r = requests.get(f'https://api.genebe.net/cloud/api-public/v1/variant',
                     params={'variant': hgvs, 'genome': 'hg38'},
                     timeout=30)
    r.raise_for_status()
    return r.json()


def whiffin_max_credible_af(prevalence, max_allelic_contribution=1.0,
                              max_genetic_contribution=1.0, penetrance=1.0):
    '''Compute gene-specific BS1 max-credible-AF (Whiffin 2017 Genet Med).

    Returns: max-credible per-allele frequency under dominant inheritance.
    For autosomal recessive, transform appropriately.
    '''
    return (prevalence * max_genetic_contribution * max_allelic_contribution) / (penetrance * 2)


def apply_bs1_ba1(grpmax_faf95, max_credible_af, ba1_threshold=0.05):
    '''Apply ClinGen SVI BS1/BA1 from gnomAD grpmax FAF95.'''
    if grpmax_faf95 is None or grpmax_faf95 == 0.0:
        return 'PM2_Supporting'
    if grpmax_faf95 > ba1_threshold:
        return 'BA1'
    if grpmax_faf95 > max_credible_af:
        return 'BS1'
    return None

Per-Operation Failure Modes

1. Stacking REVEL + BayesDel + VEST4 as independent evidence

• Trigger: Apply PP3 from multiple predictors.
• Mechanism: Predictors share training data; double-counting.
• Symptom: Inflated PP3 strength; over-classified LP.
• Fix: Use ONE predictor per variant (Pejaver 2022).

2. AlphaMissense PP3_Strong with developer 0.564 threshold

• Trigger: Apply AlphaMissense >0.564 -> PP3_Strong.
• Mechanism: 0.564 is the developer-recommended likely-pathogenic threshold; NOT the Pejaver 2022 PP3-Strong calibration; ClinGen has not endorsed.
• Symptom: Over-application of PP3.
• Fix: Use AlphaMissense as supporting evidence only; defer to Pejaver-calibrated REVEL.

3. PVS1 applied to nonsense variant in GoF gene

• Trigger: Nonsense variant in SCN5A reported as PVS1 for LQT3.
• Mechanism: SCN5A has both LoF (Brugada) and GoF (LQT3) mechanisms. PVS1 should NOT apply if LoF is not the established mechanism.
• Symptom: Wrong classification; clinical action mis-directed.
• Fix: Check ClinGen gene-disease mechanism; apply PVS1 only when LoF is established.

4. Generic ACMG instead of VCEP CSpec

• Trigger: Apply default ACMG to a variant in a gene with VCEP-specific CSpec.
• Mechanism: VCEP CSpec overrides for the gene; e.g., Hearing Loss VCEP PM2 default = supporting, BA1 = 0.5%.
• Symptom: Wrong strength applied; misclassification.
• Fix: Check https://cspec.genome.network/cspec/ui/svi/all for active VCEP; apply gene-specific CSpec.

5. PM2 at Moderate (pre-2020 SVI)

• Trigger: Apply PM2 = Moderate (2 points) per 2015 rules.
• Mechanism: SVI 2020 downgraded to PM2_Supporting (1 point).
• Symptom: ~6 variants per gene over-strengthened LP.
• Fix: Use PM2_Supporting per current SVI.

6. PS3 default Strong without OddsPath

• Trigger: Apply PS3 = Strong without OddsPath calibration.
• Mechanism: Default PS3 = Strong over-strengthens; Brnich 2020 SOP requires OddsPath > 4.3 for Strong.
• Symptom: PS3-driven over-classification.
• Fix: Apply Brnich 2020 four-step OddsPath; default move to PS3_Moderate without OddsPath > 4.3.

7. Synonymous treated as no impact

• Trigger: Filter out synonymous variants from classification pipeline.
• Mechanism: Synonymous can disrupt splicing; SpliceAI captures this.
• Symptom: Pathogenic splice-disrupting synonymous missed.
• Fix: Always run SpliceAI on synonymous variants in disease genes; PP3_Strong if DS_max >= 0.5.

8. ClinVar P + ClinGen Limited validity

• Trigger: Report variant P in gene with Limited gene-disease validity.
• Mechanism: ClinVar P is variant-level; gene-disease validity is upstream.
• Symptom: Mis-attribution to a non-disease gene.
• Fix: Apply ClinGen gene-disease validity gate (Moderate+ for clinical action); for Limited genes, require VCEP curation.

9. Variant on wrong transcript

• Trigger: HGVS-c on alt transcript; functional impact different on MANE Select.
• Mechanism: Tissue-specific isoform considerations; MANE Select 2024+ is clinical standard.
• Symptom: Wrong consequence prediction.
• Fix: Re-evaluate on MANE Select transcript; cross-check with VEP --mane_select.

Reconciliation: When Tools Disagree

| Pattern | Likely cause | Action |

|---------|-------------|--------|

| GeneBe LP vs VarSome P | Different VCEP-specific application | Check VCEP CSpec; apply gene-specific rules |

| ClinVar P vs my classification VUS | Submission stale OR my evidence incomplete | Re-curate with current evidence; check ClinVar star + freshness |

| REVEL PP3_Strong vs SpliceAI BP4 | Variant has missense impact but no splice impact | Apply ONE predictor; if splice-altering, PVS1 trumps |

| PVS1 applies but ClinGen Limited validity | Variant-level vs gene-disease tension | Treat as candidate; require VCEP or strong functional evidence |

| ClinGen VCI vs automated tool | VCI is gold standard for expert curation | Trust VCI; automated tools approximate |

| AlphaMissense >0.564 + Pejaver PP3_Supporting only | Developer threshold not calibrated | Use Pejaver REVEL or BayesDel calibration |

Quantitative Thresholds and Conventions

| Threshold | Convention | Source |

|-----------|-----------|--------|

| Tavtigian P | >= 10 points | Tavtigian 2020 |

| Tavtigian LP | 6-9 points | Tavtigian 2020 |

| Tavtigian VUS | 0-5 points | Tavtigian 2020 |

| Tavtigian LB | -1 to -6 | Tavtigian 2020 |

| Tavtigian B | <= -7 | Tavtigian 2020 |

| REVEL PP3_Strong | >= 0.932 | Pejaver 2022 |

| REVEL BP4_Strong | <= 0.016 | Pejaver 2022 |

| SpliceAI PP3_Strong | >= 0.5 (with corroboration) | Walker 2023 |

| SpliceAI minimum for PP3 | >= 0.20 | Walker 2023 |

| SpliceAI BP4_Moderate | < 0.1 | Walker 2023 |

| BA1 default | grpmax_faf95 > 5% | ClinGen SVI |

| BS1 | grpmax_faf95 > gene-specific max-credible-AF | Whiffin 2017 |

| PM2 -> PM2_Supporting | Always (post-SVI 2020) | SVI 2020 |

| PS3 OddsPath Strong | > 4.3 | Brnich 2020 |

| PVS1 LoF mechanism check | Required (do not apply if GoF) | Abou Tayoun 2018 |

| ACMG SF v3.2 | 81 genes | Miller 2023 |

| Cancer Tier I-A | FDA drug + same tumor + this biomarker | Li 2017 |

Common Errors

| Symptom | Cause | Solution |

|---------|-------|----------|

| Over-application of PP3 | Multiple predictors stacked | ONE predictor only |

| AlphaMissense PP3_Strong from dev threshold | 0.564 not calibrated | Use Pejaver-style REVEL |

| LP variant in gene with Limited validity | No gene-disease gate | Apply ClinGen gene-disease validity |

| PVS1 in GoF gene | Wrong mechanism | Check ClinGen gene-disease mechanism |

| Non-VCEP rule for VCEP-covered gene | Generic ACMG | Apply VCEP CSpec |

| PM2 = Moderate | Pre-SVI 2020 | Use PM2_Supporting |

| PS3 = Strong default | No OddsPath | Apply Brnich 2020 OddsPath |

Anticipated Reviewer Pushback

| Pushback | Standard response |

|----------|-------------------|

| "Why Tavtigian point system?" | Every modern automated classifier implements it (InterVar, GeneBe, VarSome, Franklin). The 2015 combining rules are subsumed; many P/LP combinations only emerge from points. |

| "Why ONE predictor and not REVEL + BayesDel?" | Pejaver 2022 explicit recommendation; predictors share training data. |

| "AlphaMissense PP3_Strong?" | Treated as supporting only (Schmidt 2025 / Pejaver follow-up); ClinGen has not endorsed strength-graded thresholds. |

| "PVS1 for nonsense in SCN5A LQT3" | LQT3 is GoF; LoF mechanism not established; PVS1 does not apply. |

| "Generic ACMG vs VCEP" | VCEP CSpec overrides generic; we check cspec.genome.network for active VCEP. |

| "Splice variant PP3 from SpliceAI" | Walker 2023 SVI Splicing Subgroup: minimum DS_max >= 0.2 for ANY PP3; >= 0.5 + corroborating for PP3_Strong. |

| "PM2 Moderate or Supporting?" | SVI 2020 downgraded to Supporting; we use Supporting for all classification post-2020. |

References

• Richards S et al. 2015. Standards and guidelines for the interpretation of sequence variants. *Genet Med* 17:405. (Original ACMG/AMP)
• Tavtigian SV et al. 2018. Modeling the ACMG/AMP variant classification guidelines as a Bayesian classification framework. *Genet Med* 20:1054.
• Tavtigian SV et al. 2020. Fitting a naturally scaled point system to the ACMG/AMP variant classification guidelines. *Hum Mutat* 41:1734.
• Abou Tayoun AN et al. 2018. Recommendations for interpreting the loss of function PVS1 ACMG/AMP variant criterion. *Hum Mutat* 39:1517.
• Pejaver V et al. 2022. Calibration of computational tools for missense variant pathogenicity classification. *Am J Hum Genet* 109:2163.
• Schmidt H et al. 2025. Calibration of additional missense predictors including AlphaMissense. *Genet Med* 27:e101339.
• Brnich SE et al. 2020. Recommendations for application of the functional evidence PS3/BS3 criterion using the ACMG/AMP sequence variant interpretation framework. *Genome Med* 12:3.
• Walker LC et al. 2023. ClinGen SVI Splicing Subgroup recommendations. *Am J Hum Genet* 110:1046.
• Bayrak-Toydemir P et al. 2021. Disease-specific LOD score modifications for ACMG/AMP variant interpretation. *Hum Mutat* 42:1456. (PP1 segregation)
• Cheng J et al. 2023. Accurate proteome-wide missense variant effect prediction with AlphaMissense. *Science* 381:eadg7492.
• Jaganathan K et al. 2019. Predicting splicing from primary sequence with deep learning. *Cell* 176:535. (SpliceAI)
• Zeng T et al. 2022. Predicting RNA splicing from DNA sequence using Pangolin. *Genome Biol* 23:103.
• Dawes R et al. 2023. SpliceVault predicts the precise nature of variant-associated mis-splicing. *Nat Genet* 55:324.
• Whiffin N et al. 2017. Using high-resolution variant frequencies to empower clinical genome interpretation. *Genet Med* 19:1151.
• Li MM et al. 2017. Standards and guidelines for the interpretation and reporting of sequence variants in cancer. *J Mol Diagn* 19:4. (AMP/ASCO/CAP)
• Miller DT et al. 2023. ACMG SF v3.2 list. *Genet Med* 25:100866.
• Stawinski PM et al. 2024. GeneBe; automated ACMG/AMP variant interpretation. *Clin Genet* (verify exact volume/pages in the published record before citing).
• Kopanos C et al. 2019. VarSome: the human genomic variant search engine. *Bioinformatics* 35:1978.
• Li Q, Wang K. 2017. InterVar: clinical interpretation of genetic variants. *Am J Hum Genet* 100:267.
• Xiang J et al. 2020. AutoPVS1 -- automated PVS1 decision-tree implementation (verify exact venue/year against the published code/release).
• ClinGen CSpec Registry: https://cspec.genome.network/cspec/ui/svi/all
• ClinGen VCI (Variant Curation Interface): https://curation.clinicalgenome.org/

Related Skills

• clinical-databases/variant-prioritization - Rare-disease pipeline (filters variants; this skill classifies)
• clinical-databases/clinvar-lookup - ClinVar evidence aggregation
• clinical-databases/gnomad-frequencies - BS1/BA1 with Whiffin FAF95
• clinical-databases/myvariant-queries - Aggregated annotation pull
• variant-calling/clinical-interpretation - Clinical reporting workflow