Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA06.017r


Attachment:A

Policy #:MA06.017r

Description:Services that are Considered Medically Necessary

Title:Molecular Diagnostics


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.


The following procedure codes and services are considered medically necessary and, therefore, covered when the general molecular diagnostic testing criteria in the main policy are met.

Tier 02 CPT codes (81400 - 81408) for genetic testing services are nonspecific in nature. Individual tests which do not have a specific genetic testing code may be represented with Tier 02 CPT genetic testing codes. In this attachment there is a list of specific genetic tests for each of the Tier 02 CPT genetic testing codes, which may be considered medically necessary and, therefore, covered when the general molecular diagnostic testing criteria in the main policy are met.
Procedure
Codes
0023U
81265
81266
81267
81268
81291
81370
81371
81372
81373
81374
81375
81376
81377
81378
81379
81380
81381
81382
81383
81400
81401
81402
81403
81404
81405
81406
81407
81408
82955
82960
87152
87153
87493
87631
87632
87633
87661
87902
87910
87912
88182
88245
88248
88249
88261
88262
88263
88264
88267
88269
88280
88283
88285
88289
S3840
S3841
S3842
S3846
S3850
S3853
S3865
S3866

Physician Interpretation and Report

HCPCS code G0452 is considered medically necessary and, therefore, covered when performed for services that are considered medically necessary by the Company.
CodeNarrative
G0452Molecular pathology procedure; physician interpretation and report


Version Effective Date: 01/01/2020
Version Issued Date: 01/03/2020
Version Reissued Date: N/A

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