Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA06.017r


Attachment:B

Policy #:MA06.017r

Description:Services that are Considered Medically Necessary with Criteria

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.



Attachment B lists codes and services that may represent medically necessary molecular diagnostic testing and may be covered when all of the general molecular diagnostic testing criteria listed in the main policy are met and the test-specific criteria outlined below are met.

Ashkenazi Jewish Genetic Carrier Screening Panel

Genetic testing is considered medically necessary and, therefore, covered for services represented by the CPT codes: 81242, 81250, 81251, 81255, and 81290 when any of the following criteria are met:
  • Reproductive partners who are planning pregnancy or are pregnant, where at least one partner is a member of Ashkenazi Jewish heritage
  • High-risk individuals with a positive family history of the disease

In addition to the medical necessity criteria above:

CPT code 81242 is covered if the individual's age is less than 65.
CPT codes 81250, 81251, 81255, and 81290 are covered if the individual's age is less than 40.

Services represented by the CPT codes 81242, 81250, 81251, 81255, and 81290 are considered not medically necessary and, therefore, not covered for general population screening.
Code
81242
81250
81251
81255
81290

BRCA Testing

Genetic testing is considered medically necessary and, therefore, covered for services represented by the CPT codes 81212, 81215, 81216, and 81217 when the medical necessity criteria in policy (MA06.010), entitled Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations, are met.
Code
81212
81215
81216
81217

CYP450 Genotyping for CYP2C19 in Pharmacogenomic Testing

See the current version of the policy (MA06.008) entitled Pharmacogenomic Testing to Determine Drug Sensitivity for medical necessity criteria. Additionally, see Attachment E of this policy (MA06.017) for information on when CPT code 81225 may be covered via Coverage with Evidence Development (CED), registry-based approach, or other properly designed methods of investigation when these investigations are approved by the Medicare Administrative Contractor (MAC).

Code
81225

EGFR for Pharmacogenomic Testing

See the current version of the policy entitled Pharmacogenomic Testing to Determine Drug Sensitivity, MA06.008 for medical necessity criteria.
Code
81235

Hereditary Hypercoagulability

Genetic testing is considered medically necessary and, therefore, covered for services represented by the CPT codes 81240 and 81241 when any of the following indications are met:

  • Individuals age 50 or under with any venous thrombosis
  • Individuals with a positive family history of venous thrombosis
  • Venous thrombosis in pregnant women or women taking oral contraceptives
  • Myocardial infarction in female smokers under age 50
  • Females with recurrent pregnancy loss, or second trimester miscarriage, intrauterine fetal growth retardation, or stillbirth
  • Individuals with venous thrombosis, age >50, except when active malignancy is present

Services represented by the CPT codes 81240 and 81241 are considered not medically necessary and, therefore, not covered for general population screening.
Code
81240
81241

GJB2 and GJB6

Genetic testing is considered medically necessary and, therefore, covered for individuals of age less than 40 for services represented by the CPT codes 81252, 81253, and 81254, and HCPCS code S3844 for the diagnosis of DFNB1 or DFNA3 in individuals with nonsyndromic hearing loss.

Code
81252
81253
81254
S3844

Hereditary Hemochromatosis

Genetic testing is considered medically necessary and, therefore, covered for services represented by the CPT code 81256 when the individual is less than 65 years of age and either of the following indications are met:

  • Individual with clinical symptoms of iron overload and serum transferrin saturation ≥45%, and /or ferritin above the upper limit of normal
  • Individual with a family history of hemochromatosis
Code
81256

KRAS for for Pharmacogenomic Testing

Genetic testing is considered medically necessary and, therefore, covered for services represented by the CPT code 81275 for KRAS sequence variant testing to predict response to treatment with anti-EGFR monoclonal antibodies (ie, testing for cetuximab and panitumumab monotherapy and for combination therapy of cetuximab with irinotecan or oxaliplatin) in individuals with metastatic colorectal cancer who have failed or are refractory to first- or second-line chemotherapy.

See the current version of the policy entitled Pharmacogenomic Testing to determine Drug Sensitivity, MA06.008 for medical necessity criteria.

Code
81275

MLH1 and MSH2

Genetic testing is considered medically necessary and, therefore, covered for services represented by the CPT codes 81292, 81293 and 81294, 81295, 81296 and 81297 when the medical necessity criteria in policy entitled (MA06.012) Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) are met.

Code
81292
81293
81294
81295
81296
81297

MSH6

Genetic testing is considered medically necessary and, therefore, covered for services represented by the CPT codes 81298, 81299, and 81300 when the medical necessity criteria in the policy (MA06.012) entitled Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) are met.

Code
81298
81299
81300

PMS2

Genetic testing is considered medically necessary and, therefore, covered for services represented by the CPT codes 81317, 81318, and 81319 when the medical necessity criteria in the policy (MA06.012) entitled Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) are met.

Code
81317
81318
81319

Microsatellite Instability Analysis

Genetic testing is considered medically necessary and, therefore, covered for services represented by the CPT code 81301 when the medical necessity criteria in the policy (MA06.012) entitled Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) are met.
Code
81301

APC Mutational Analysis

Genetic testing is considered medically necessary and, therefore, covered for services represented by the CPT codes 81201, 81202, and 81203 when the medical necessity criteria in the policy (MA06.012) entitled Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) are met.
Code
81201
81202
81203

PTEN

Genetic testing is considered medically necessary and, therefore, covered for individual's of age less than 65 for services represented by the CPT codes 81321, 81322, and 81323 for any of the following:
  • To confirm the diagnosis when an individual has clinical signs of a PTEN hamartoma tumor syndrome.
  • Genetic testing for a PTEN mutation may be considered medically necessary in a first -degree relative* of a proband with a known PTEN mutation.

Genetic testing for a PTEN mutation is considered experimental/investigational and, therefore, not covered for all other indications, including, but not limited to, prenatal testing.

* Testing a first-degree relative

When a deleterious familial PTEN mutation is known, testing for the specific familial mutation should be performed.

If there is no known familial PTEN mutation, comprehensive testing includes full sequence analysis and deletion/duplication analyses. The order of testing to optimize yield would be 1) Sequencing of PTEN exons 1-9 and flanking intron regions. If no mutation is identified, perform 2) deletion/duplication analysis. If no mutation is identified, consider, 3) Promoter analysis (research). Promoter analysis detects mutations in ~10% of individuals with CS who do not have an identifiable mutation in the PTEN coding region.
Code
81321
81322
81323

PMP22

Genetic testing is considered medically necessary for individuals less than 50 years of age and, therefore, covered for services represented by the CPT codes 81324, 81325, and 81326 for any of the following:

  • For an individual with an oncology indication with unexplained or preexisting familial neuropathy consistent with Charcot-Marie-Tooth disease.
  • For prenatal or preimplantation genetic diagnosis of Charcot-Marie-Tooth disease Type 1A.
Code
81324
81325
81326

Alpha-1 Antitrypsin Deficiency

Genetic testing is considered medically necessary and, therefore, covered for services represented by CPT code 81332 when all of the following conditions are met:
  • Individual is suspected of having alpha-1 antitrypsin deficiency because of clinical factors and/or because the patient may be at high risk of having alpha-1 antitrypsin deficiency due to a first-degree relative with AAT deficiency; AND
  • Individual has a serum alpha-1 antitrypsin level in the range of severe deficiency
  • Individual's age is less than 65
Code
81332

T Cell Antigen Beta and Gamma

Genetic testing is considered medically necessary and, therefore, covered for services represented by the CPT codes 81340, 81341, and 81342 when results from these tests are interpreted in the context of clinical, histologic, and immunophenotypic data concerning leukemia and lymphoma, especially when monitoring minimal residual disease.

Code
81340
81341
81342

Fetal Fibronectin

The fetal fibronectin (fFN) immunoassay is considered medically necessary and, therefore, covered for women who meet all of the following indications:
  • Their symptoms are suggestive of current preterm labor severe enough to potentially warrant hospital admission for tocolysis.
  • Lab results can be provided in order to make timely treatment determinations (i.e., rapid test results should be provided in less than an hour).
  • Singleton or twin gestation between 24 weeks and less than 35 weeks.
  • Intact amniotic membranes.
  • Cervical dilation less than 3 cm.

The fFN immunoassay is considered experimental/investigational for all other indications including, but not limited to:
  • As part of routine clinical monitoring in asymptomatic pregnant women with singleton gestation and no risk factors for PTL.
  • As part of routine clinical monitoring in asymptomatic pregnant women at risk for PTL, including those with a history of multiple gestations, preterm birth, uterine malformation, cervical incompetence, or a history of two or more spontaneous second-trimester abortions.
  • As part of routine clinical monitoring in women with triplet or higher-order gestations, intact membranes, cervical dilation less than 3 cm, and who are experiencing symptoms suggestive of PTL.
  • As a test to identify women at term being considered for induction who are likely to deliver within 24 to 48 hours and, therefore, do not require induction.
Code
82731

AlloMap™ Molecular Expression Testing for Heart Transplant Rejection

Genetic testing is considered medically necessary and, therefore, covered for services represented by the CPT code 86849 when the criteria in the current version of the policy # MA06.015 are met.
Code
86849

Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping

Genetic testing is considered medically necessary and, therefore, covered for services represented by the CPT code 87900, 87901, 87903, 87904, and 87906 when the criteria in the current version of the policy # MA06.011 are met.
Code
87900
87901
87903
87904
87906

Preimplantation Genetic Diagnosis (PGD) Testing

PREIMPLANTATION GENETIC DIAGNOSIS

PGD testing is considered medically necessary and, therefore, covered as an adjunct to in vitro fertilization (IVF) in otherwise fertile individuals/couples who meet at least ONE of the following criteria:
  • For evaluation of an embryo at an identified elevated risk of a genetic disorder such as:
  • Both partners are known carriers of a single autosomal recessive gene (eg, cystic fibrosis, phenylketonuria).
  • One partner is a known carrier of a single gene autosomal recessive disorder and the partners have one offspring that has been diagnosed with the recessive disorder (eg, Tay-Sachs disease).
  • One partner is a known carrier of a single gene autosomal dominant disorder (eg, myotonic dystrophy, neurofibromatosis, Huntington's chorea).
  • One partner is a known carrier of a single X-linked disorder (eg, fragile X syndrome, hemophilia, Lesch-Nyhan syndrome, Fabry disease).
  • For evaluation of an embryo at an identified elevated risk for chromosomal abnormality (eg, unbalanced translocation, microdeletion/duplication, aneuploidy) such as:
  • One of the partners is known to harbor a balanced or unbalanced chromosomal translocation (ie, a rearrangement of chromosome material with either no extra or missing material, or the exchange of chromosomal material is unequal, resulting in extra or missing genes).
  • Prior parental history of a child with aneuploidy or the change in the number of chromosomes that can lead to a chromosomal abnormality.

PGD is considered not medically necessary and, therefore, not covered as an adjunct to IVF in individuals and/or couples undergoing IVF due to infertility when any of the following conditions are present:
  • When used as a substitute for usual genetic testing for women at higher risk based solely on maternal age (i.e., ovum used from mother or egg donor older than 35 years) when the medical necessity criteria stated above are not met.
  • There is no identified elevated risk of genetic disorder or chromosomal abnormality in the embryo (as stated in the above criteria).

Preimplantation genetic diagnosis (PGD) as an adjunct to IVF in all other uses is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.


PREIMPLANTATION GENETIC SCREENING

Preimplantation genetic screening (PGS) as an adjunct to IVF is considered experimental/investigational and, therefore, not covered, for use due to advanced maternal age or in the absence of a known genetic or chromosomal defect because the safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

Benefits for genetic testing associated with PGD testing are available to all individuals who meet the medical necessity criteria listed above. However, some procedures associated with PGD testing (eg, egg retrieval, IVF) require a fertility rider or mandate in order to be covered by the Company. Individual member benefits must be verified.
Code
88271
88272
88273
88274
88275
88291
88365

MAMMAPRINT®

The MammaPrint® is medically necessary and, therefore, covered for individuals with breast cancer when ordered by the treating physician, when being used for diagnosis and treatment decisions, and when all of the following criteria are met:
  • The test is used for stage I and stage II invasive breast cancer.
  • Less than 6 months has elapsed since the initial diagnosis.
  • Chemotherapy has not been initiated.
  • The tumor size is less than 5.0 cm.
  • The breast cancer is lymph node--negative.
  • The breast carcinoma is ER-positive or ER-negative.
  • Tamoxifen independent.
  • There are nodal micrometastases (smaller than 2.0 mm in size).
  • There are no more than three positive lymph nodes.

The following ICD-10 codes are the diagnosis codes covered for MammaPrint when reported with HCPCS code S3854 or Unlisted code 84999 (Unlisted molecular pathology procedure):

C50.011 Malignant neoplasm of nipple and areola, right female breast
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.211 Malignant neoplasm of upper inner quadrant of right female breast
C50.212 Malignant neoplasm of upper inner quadrant of left female breast
C50.311 Malignant neoplasm of lower inner quadrant of right female breast
C50.312 Malignant neoplasm of lower inner quadrant of left female breast
C50.411 Malignant neoplasm of upper outer quadrant of right female breast
C50.412 Malignant neoplasm of upper outer quadrant of left female breast
C50.511 Malignant neoplasm of lower outer quadrant of right female breast
C50.512 Malignant neoplasm of lower outer quadrant of left female breast
C50.611 Malignant neoplasm of axillary tail of right female breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.911 Malignant neoplasm of unspecified site of right female breast
C50.912 Malignant neoplasm of unspecified site of left female breast
C50.021 Malignant neoplasm of nipple and areola, right male breast
C50.022 Malignant neoplasm of nipple and areola, left male breast
C50.121 Malignant neoplasm of central portion of right male breast
C50.122 Malignant neoplasm of central portion of left male breast
C50.221 Malignant neoplasm of upper inner quadrant of right male breast
C50.222 Malignant neoplasm of upper inner quadrant of left male breast
C50.321 Malignant neoplasm of lower inner quadrant of right male breast
C50.322 Malignant neoplasm of lower inner quadrant of left male breast
C50.421 Malignant neoplasm of upper outer quadrant of right male breast
C50.422 Malignant neoplasm of upper outer quadrant of left male breast
C50.521 Malignant neoplasm of lower outer quadrant of right male breast
C50.522 Malignant neoplasm of lower outer quadrant of left male breast
C50.621 Malignant neoplasm of axillary tail of right male breast
C50.622 Malignant neoplasm of axillary tail of left male breast
C50.821 Malignant neoplasm of overlapping sites of right male breast
C50.822 Malignant neoplasm of overlapping sites of left male breast
Z17.0 Estrogen receptor positive status [ER+] [Code first malignant neoplasm of breast (C50. )]
Z17.1 Estrogen receptor negative status [ER ] [Code first malignant neoplasm of breast (C50. )]

Code
84999
S3854

ONCOTYPE DX® for Breast Cancer

The Oncotype DX® test, is medially necessary and, therefore, covered as an assay of genetic expression in tumor tissues for breast cancer prognosis when all of the following criteria are met:
  • The individual's breast cancer is being treated with tamoxifen or aromatase inhibitors.
  • Clinical evidence that the test will significantly contribute to the prognosis and management of the individual is documented.
  • Less than 6 months has elapsed since the initial diagnosis.

AND one of the following:
  • Clinical diagnosis of stage I or stage II hormone receptor--positive, node-negative, HER2-negative cancer of the breast
  • ER-positive micrometastases of carcinoma of the breast
  • Micrometastases are defined as tumor deposits greater than 0.2 mm but not greater than 2.0 mm in largest dimension.
  • ER-positive breast carcinoma with 1-3 positive nodes

The following ICD-10 codes are the diagnosis codes covered for Oncotype DX Breast when reported with Unlisted code 84999 (Unlisted molecular pathology procedure):

C50.011 Malignant neoplasm of nipple and areola, right female breast
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.019 Malignant neoplasm of nipple and areola, unspecified female breast
C50.021 Malignant neoplasm of nipple and areola, right male breast
C50.022 Malignant neoplasm of nipple and areola, left male breast
C50.029 Malignant neoplasm of nipple and areola, unspecified male breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.119 Malignant neoplasm of central portion of unspecified female breast
C50.121 Malignant neoplasm of central portion of right male breast
C50.122 Malignant neoplasm of central portion of left male breast
C50.129 Malignant neoplasm of central portion of unspecified male breast
C50.211 Malignant neoplasm of upper inner quadrant of right female breast
C50.212 Malignant neoplasm of upper inner quadrant of left female breast
C50.219 Malignant neoplasm of upper inner quadrant of unspecified female breast
C50.221 Malignant neoplasm of upper inner quadrant of right male breast
C50.222 Malignant neoplasm of upper inner quadrant of left male breast
C50.229 Malignant neoplasm of upper inner quadrant of unspecified male breast
C50.311 Malignant neoplasm of lower inner quadrant of right female breast
C50.312 Malignant neoplasm of lower inner quadrant of left female breast
C50.319 Malignant neoplasm of lower inner quadrant of unspecified female breast
C50.321 Malignant neoplasm of lower inner quadrant of right male breast
C50.322 Malignant neoplasm of lower inner quadrant of left male breast
C50.329 Malignant neoplasm of lower inner quadrant of unspecified male breast
C50.411 Malignant neoplasm of upper outer quadrant of right female breast
C50.412 Malignant neoplasm of upper outer quadrant of left female breast
C50.419 Malignant neoplasm of upper outer quadrant of unspecified female breast
C50.421 Malignant neoplasm of upper outer quadrant of right male breast
C50.422 Malignant neoplasm of upper outer quadrant of left male breast
C50.429 Malignant neoplasm of upper outer quadrant of unspecified male breast
C50.511 Malignant neoplasm of lower outer quadrant of right female breast
C50.512 Malignant neoplasm of lower outer quadrant of left female breast
C50.519 Malignant neoplasm of lower outer quadrant of unspecified female breast
C50.521 Malignant neoplasm of lower outer quadrant of right male breast
C50.522 Malignant neoplasm of lower outer quadrant of left male breast
C50.529 Malignant neoplasm of lower outer quadrant of unspecified male breast
C50.611 Malignant neoplasm of axillary tail of right female breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.619 Malignant neoplasm of axillary tail of unspecified female breast
C50.621 Malignant neoplasm of axillary tail of right male breast
C50.622 Malignant neoplasm of axillary tail of left male breast
C50.629 Malignant neoplasm of axillary tail of unspecified male breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.819 Malignant neoplasm of overlapping sites of unspecified female breast
C50.821 Malignant neoplasm of overlapping sites of right male breast
C50.822 Malignant neoplasm of overlapping sites of left male breast
C50.829 Malignant neoplasm of overlapping sites of unspecified male breast
C50.911 Malignant neoplasm of unspecified site of right female breast
C50.912 Malignant neoplasm of unspecified site of left female breast
C50.919 Malignant neoplasm of unspecified site of unspecified female breast
C50.921 Malignant neoplasm of unspecified site of right male breast
C50.922 Malignant neoplasm of unspecified site of left male breast
C50.929 Malignant neoplasm of unspecified site of unspecified male breast
D05.00 Lobular carcinoma in situ of unspecified breast
D05.01– Lobular carcinoma in situ of right breast
D05.02 Lobular carcinoma in situ of left breast
D05.10 Intraductal carcinoma in situ of unspecified breast
D05.11 Intraductal carcinoma in situ of right breast
D05.12 Intraductal carcinoma in situ of left breast
D05.80 Other specified type of carcinoma in situ of unspecified breast
D05.81 Other specified type of carcinoma in situ of right breast
D05.82 Other specified type of carcinoma in situ of left breast
D05.90 Unspecified type of carcinoma in situ of unspecified breast
D05.91 Unspecified type of carcinoma in situ of right breast
D05.92 Unspecified type of carcinoma in situ of left breast
Z17.0 Estrogen receptor positive status [ER+]


The Oncotype DX® test is covered once per diagnosis of breast cancer, per individual. As is true for other clinical laboratory tests, controls and confirmatory results are considered integral to the initial reimbursement for the test.

Additionally, the Oncotype DX® test is a covered service in the event that (although rare) a diagnosis of breast cancer in a contralateral breast, of a different cell type or a different gene expression, would be obtained and documented.

All other uses for the Oncotype DX® test are considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

Code
84999


Nucleic Acid Sequencing-Based Testing of Maternal Plasma
Genetic testing is considered medically necessary and, therefore, covered for services represented by CPT code 81507 when the following criteria are met:
  • In women with high-risk singleton pregnancies undergoing screening for fetal aneuploidy.
Karyotyping would be necessary to exclude the possibility of a false positive nucleic acid sequencing–based test.
Before testing, women should be counseled about the risk of a false positive test.

Nucleic acid sequencing-based testing of maternal plasma for fetal aneuploidy is considered not medically necessary and, therefore, not covered in women with low- or average-risk singleton pregnancies.

Nucleic acid sequencing-based testing of maternal plasma for fetal aneuploidy is considered experimental/investigational in women with twin or multiple pregnancies.
Code
81507
81420

Vysis Kit

Vysis Kit is considered medically necessary and, therefore, covered for the following ICD-10 diagnosis codes when this test is reported with with CPT codes 88367 and 88368:

C34.01 Malignant neoplasm of right main bronchus
C34.02 Malignant neoplasm of left main bronchus
C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
C34.2 Malignant neoplasm of middle lobe, bronchus or lung
C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
C34.91 Malignant neoplasm of unspecified part of right bronchus or lung
C34.92 Malignant neoplasm of unspecified part of left bronchus or lung

Code
88367
88368

CellSearch™

For more information and medical necessity criteria, see the current version of the policy entitled Circulating Tumor Cell (CTC) Assay, MA06.030.

Code
86152
86153

OVA1 and ROMA

OVA1™ and ROMA1™ proteomic testing as an adjunctive test for the evaluation of ovarian (adnexal) masses is considered medically necessary and, therefore, covered when all of the following criteria are met:

  • The individual is over 18 years of age.
  • Ovarian adnexal mass is present, for which surgery is planned.
  • The individual has not yet been referred to an oncologist.
  • For OVA1™ Test: other clinical and radiological evaluation for ovarian cancer does not indicate malignancy.
Code
81500
81503

Urovysion Bladder Cancer Kit

The use of UroVysionTM Bladder Cancer Kit is considered medically necessary and, therefore, covered to detect aneuploidy for chromosomes 3,7,17, and loss of the 9p2l locus via fluorescence in situ hybridization (FISH) in urine specimens for the purpose of:

  • Diagnosing bladder cancer in individuals with hematuria; OR
  • Monitoring for tumor recurrence in individuals with previously diagnosed bladder cancer.
Code
88120
88121

VeriStrat Assay Testing

VeriStrat® assay testing, a mass spectrophotometric, serum-based predictive proteomics assay, is considered medically necessary and, therefore, covered for individuals with NSCLC being considered for treatment with EGFR inhibitors (e.g. Erlotinib) where first-line EGFR mutation testing is either wild-type or not able to be tested (e.g., tissue may not be available).
Code
84999

Alpha Thalassemia

Genetic Testing for Alpha Thalassemia is considered medically necessary and, therefore, covered if the individual's age is less than 65 years.
Code
81257
S3845

MGMT Testing

MGMT testing is medically necessary and, therefore, covered when ALL of the following are met:

  • Tumor type is an anaplastic glioma (e.g. glioblastoma multiforme (GBM), anaplastic astrocytoma (AA), anaplastic oligoastrocytoma (AOA), anaplastic oligodendroglioma (AO)) AND
  • Individual's age = or > 65 years old AND
  • Individuals are able to tolerate temozolomide therapy or radiation therapy AND
  • Providers will use the result to determine whether radiation vs. radiation and combined temozolomide or temozolomide alone is appropriate as first line adjuvant treatment, AND
  • Temozolomide will not be given as first line therapy in patients where the MGMT methylation status is not elevated

The following ICD-10 codes are the diagnosis codes covered for MGMT Gene promoter when reported with CPT code 81287:

C71.0 Malignant neoplasm of cerebrum, except lobes and ventricles
C71.1 Malignant neoplasm of frontal lobe
C71.2 Malignant neoplasm of temporal lobe
C71.3 Malignant neoplasm of parietal lobe
C71.4 Malignant neoplasm of occipital lobe
C71.5 Malignant neoplasm of cerebral ventricle
C71.6 Malignant neoplasm of cerebellum
C71.7 Malignant neoplasm of brain stem
C71.8 Malignant neoplasm of overlapping sites of brain
C71.9 Malignant neoplasm of brain, unspecified

Code
81287

Pathwork

Pathwork is considered medically necessary and, therefore, covered for the following ICD-10 diagnosis codes when this test is reported with CPT code 81504:

C18.1 Malignant neoplasm of appendix
C18.9 Malignant neoplasm of colon, unspecified
C22.0 Liver cell carcinoma
C22.2 Hepatoblastoma
C22.3 Angiosarcoma of liver
C22.4 Other Sarcomas of liver
C22.7 Other specified carcinomas of liver
C22.8 Malignant neoplasm of liver, primary, unspecified as to type
C22.9 Malignant neoplasm of liver, not specified as primary or secondary
C25.2 Malignant neoplasm of tail of pancreas
C25.7 Malignant neoplasm of other parts of the pancreas
C25.8 Malignant neoplasm of overlapping sites of pancreas
C25.9 Malignant neoplasm of pancreas, unspecified
C33 Malignant neoplasm of trachea
C34.00 Malignant neoplasm of unspecified main bronchus
C34.01 Malignant neoplasm of right main bronchus
C34.02 Malignant neoplasm of left main bronchus
C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung
C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung
C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung
C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
C34.92 Malignant neoplasm of overlapping sites of left bronchus and lung
C43.51 Malignant melanoma of anal skin
C43.52 Malignant melanoma of skin of breast
C43.59 Malignant melanoma of other part of trunk
C45.9 Mesothelioma, unspecified
C47.0 Malignant neoplasm of peripheral nerves of head, face, and neck
C47.9 Malignant neoplasm of peripheral nerves and autonomic nervous system, unspecified
C48.0 Malignant neoplasm of retroperitoneum
C49.0 Malignant neoplasm of connective and soft tissue of head, face, and neck
C49.9 Malignant neoplasm of connective and soft tissue, unspecified
C50.411 Malignant neoplasm of upper outer quadrant of right female breast
C50.419 Malignant neoplasm of upper outer quadrant of left female breast
C50.419 Malignant neoplasm of upper outer quadrant of unspecified female breast
C50.511 Malignant neoplasm of lower outer quadrant of right female breast
C50.512 Malignant neoplasm of lower outer quadrant of left female breast
C50.519 Malignant neoplasm of lower outer quadrant of unspecified female breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.819 Malignant neoplasm of overlapping sites of unspecified female breast
C50.911 Malignant neoplasm of unspecified site of right female breast
C50.912 Malignant neoplasm of unspecified site of left female breast
C50.919 Malignant neoplasm of unspecified site of unspecified female breast
C56.1 Malignant neoplasm of right ovary
C56.2 Malignant neoplasm of left ovary
C56.9 Malignant neoplasm of unspecified ovary
C61 Malignant neoplasm of prostate
C64.1 Malignant neoplasm of right kidney, except renal pelvis
C64.2 Malignant neoplasm of left kidney, expect renal pelvis
C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis
C67.5 Malignant neoplasm of bladder neck
C67.9 Malignant neoplasm of bladder, unspecified
C76.0 Malignant neoplasm of head, face and neck
C77.0 Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck
C77.1 Secondary and unspecified malignant neoplasm of intrapelvia lymph nodes
C77.2 Secondary and unspecified malignant neoplasm of intra abdominal lymph nodes
C77.3 Secondary unspecified malignant neoplasm of axilla and upper limb lymph nodes
C77.4 Secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes
C77.5 Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes
C77.8 Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions
C77.9 Secondary and unspecified malignant neoplasm of lymph node, unspecified
C78.00 Secondary and unspecified malignant neoplasm of unspecified lung
C78.01 Secondary malignant neoplasm of right lung
C78.02 Secondary malignant neoplasm of left lung
C78.5 Secondary malignant neoplasm of large intestine and rectum
C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct
C79.00 Secondary malignant neoplasm of unspecified kidney and renal pelvis
C79.01 Secondary malignant neoplasm of right kidney and renal pelvis
C79.02 Secondary malignant neoplasm of left kidney and renal pevis
C79.2 Secondary malignant neoplasm of skin
C79.31 Secondary malignant neoplasm of brain
C79.51 Secondary malignant neoplasm of bone
C79.52 Secondary malignant neoplasm of bone marrow
C79.60 Secondary malignant neoplasm of unspecified ovary
C79.61 Secondary malignant neoplasm of right ovary
C79.62 Secondary malignant neoplasm of left ovary
C79.89 Secondary malignant neoplasm of other specified sites
C79.9 Secondary malignant neoplasm of unspecified site
C80.0 Disseminated malignant neoplasm, unspecified
C80.1 Malignant (primary) neoplasm, unspecified
C82.57 Diffuse follicle center lymphoma, spleen
C84.97 Mature T/NK cell lymphomas, unspecified, spleen
C84.87 Cutaneous T cell lymphoma, unspecified, spleen
C85.17 Unspecified B cell lymphoma, spleen
C85.27 Mediastinal (thymic) large B cell lymphoma, spleen
C85.87 Other specified types of non Hodgkin lymphoma, spleen
C85.97 Non Hodgkin lymphoma, unspecified spleen
C86.1 Hepatosplenic T cell lymphoma
D01.5 Carcinoma in situ of liver, gallbladder and bile ducts
D01.7 Carcinoma in situ of other specified digestive oragans
D01.9 Carcinoma in situ of od digestive organ, unspecified
D02.20 Carcinoma in situ of unspecified bronchus and lung
D02.21 Carcinoma in situ of right bronchus and lung
D02.22 Carcinoma in situ of left bronchus and lung
D03.51 Melanoma in situ of anal skin
D03.52 Melanoma in situ of breast (skin) (soft tissue)
D03.59 Melanoma in situ of other part of trunk
D49.0 Neoplasm of unspecified behavior of digestive system
D49.1 Neoplasm of unspecified behavior of respiratory system
D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin
D49.3 Neoplasm of unspecified behavior of breast
D49.4 Neoplasm of unspecified behavior of bladder
D49.511: Neoplasm of unspecified behavior of right kidney
D49.512: Neoplasm of unspecified behavior of left kidney
D49.519: Neoplasm of unspecified behavior of unspecified kidney
D49.59: Neoplasm of unspecified behavior of other genitourinary organ
D49.6 Neoplasm of unspecified behavior of brain
D49.7 Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system
D49.89 Neoplasm of unspecified behavior of other specified sites
D49.9 Neoplasm of unspecified behavior of unspecified sites

Code
81504

Individual Biomarkers for Oncology

See the Medicare Advantage Policy on Biomarker for Oncology (MA 06.022) for information on the specific Tier 01 CPT codes listed in this table, when these procedure codes represent medically necessary and, therefore, covered testing as individual biomarkers for oncology. The Medicare Advantage Policy on Biomarker for Oncology (MA 06.022) also details information on individual biomarkers for oncology, that are represented by the Tier 02 CPT codes (81400-81408) and Unlisted code 81479 (Unlisted molecular pathology procedure), which are medically necessary and, therefore, covered.
Code
81206
81207
81208
81210
81235
81245
81261
81262
81263
81264
81270
81275
81287
81292
81293
81294
81301
81310
81315
81316
81321
81322
81323
81340
81342


This list represents services that are considered MN but lack a specific CPT or HCPCS code. Since Not Otherwise Classified (NOC), unlisted, and miscellaneous codes can be reported with many services, the intent of this section is to provide direction only for the specific genetic testing services listed below. The following tests are considered medically necessary and, therefore, covered, when medical necessity criteria are met.
Unlisted,Miscellaneous
Code(s)
Tests
84999Oncotype DX Colon Cancer Assay

The 12-gene expression test (Oncotype DX® colon cancer test) is medically necessary and, therefore, covered when used for individuals diagnosed with Stage II colon cancer for the following ICD-10 codes diagnosis codes when this assay is reported with Unlisted code 84999 (Unlisted molecular pathology procedure):

C18.0 Malignant neoplasm of cecum
C18.1 Malignant neoplasm of appendix
C18.2 Malignant neoplasm of ascending colon
C18.3 Malignant neoplasm of hepatic flexure
C18.4 Malignant neoplasm of transverse colon
C18.6 Malignant neoplasm of descending colon
C18.7 Malignant neoplasm of sigmoid colon
C18.5 Malignant neoplasm of splenic flexure
C18.8 Malignant neoplasm of overlapping sites of colon
C18.9 Malignant neoplasm of colon, unspecified
C19 Malignant neoplasm of rectosigmoid junction
C20 Malignant neoplasm of rectum
C21.1 Malignant neoplasm of anal canal

84999Cancer Type ID

Cancer Type ID is considered medically necessary and, therefore, covered for the following ICD-10 diagnosis codes when this test is reported with Unlisted code 84999 (Unlisted molecular pathology procedure):

C18.1 Malignant neoplasm of appendix
C18.9 Malignant neoplasm of colon, unspecified
C22.0 Liver cell carcinoma
C22.2 Hepatoblastoma
C22.3 Angiosarcoma of liver
C22.4 Other sarcomas of liver
C22.7 Other specified carcinomas of liver
C22.8 Malignant neoplasm of liver, primary, unspecified as to type
C22.9 Malignant neoplasm of liver, not specified as primary or secondary
C25.2 Malignant neoplasm of tail of pancreas
C25.7 Malignant neoplasm of other parts of pancreas
C25.8 Malignant neoplasm of overlapping sites of pancreas
C25.9 Malignant neoplasm of pancreas, unspecified
C48.0 Malignant neoplasm of retroperitoneum
C33 Malignant neoplasm of trachea
C34.01 Malignant neoplasm of right main bronchus
C34.02 Malignant neoplasm of left main bronchus
C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
C34.2 Malignant neoplasm of middle lobe, bronchus or lung
C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
C34.91 Malignant neoplasm of unspecified part of right bronchus or lung
C34.92 Malignant neoplasm of unspecified part of left bronchus or lung
C47.0 Malignant neoplasm of peripheral nerves of head, face and neck
C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck
C47.9 Malignant neoplasm of peripheral nerves and autonomic nervous system, unspecified
C49.9 Malignant neoplasm of connective and soft tissue, unspecified
C43.51 Malignant melanoma of anal skin
C43.52 Malignant melanoma of skin of breast
C43.59 Malignant melanoma of other part of trunk
D03.51 Melanoma in situ of anal skin
D03.52 Melanoma in situ of breast (skin) (soft tissue)
D03.59 Melanoma in situ of other part of trunk
C50.411 Malignant neoplasm of upper outer quadrant of right female breast
C50.412 Malignant neoplasm of upper outer quadrant of left female breast
C50.511 Malignant neoplasm of lower outer quadrant of right female breast
C50.512 Malignant neoplasm of lower outer quadrant of left female breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.911 Malignant neoplasm of unspecified site of right female breast
C50.912 Malignant neoplasm of unspecified site of right female breast
C56.1 Malignant neoplasm of right ovary
C56.2 Malignant neoplasm of left ovary
C61 Malignant neoplasm of prostate
C67.5 Malignant neoplasm of bladder neck
C67.9 Malignant neoplasm of bladder, unspecified
C64.1 Malignant neoplasm of right kidney, except renal pelvis
C64.2 Malignant neoplasm of left kidney, except renal pelvis
C76.0 Malignant neoplasm of head, face and neck
C77.0 Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck
C77.1 Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes
C77.2 Secondary and unspecified malignant neoplasm of intra abdominal lymph nodes
C77.3 Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes
C77.4 Secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes
C77.5 Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes
C77.8 Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions
C77.9 Secondary and unspecified malignant neoplasm of lymph node, unspecified
C78.01 Secondary malignant neoplasm of right lung
C78.02 Secondary malignant neoplasm of left lung
C78.5 Secondary malignant neoplasm of large intestine and rectum
C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct
C79.01 Secondary malignant neoplasm of right kidney and renal pelvis
C79.02 Secondary malignant neoplasm of left kidney and renal pelvis
C79.2 Secondary malignant neoplasm of skin
C79.31 Secondary malignant neoplasm of brain
C79.49 Secondary malignant neoplasm of other parts of nervous system
C79.51 Secondary malignant neoplasm of bone
C79.52 Secondary malignant neoplasm of bone marrow
C79.61 Secondary malignant neoplasm of right ovary
C79.62 Secondary malignant neoplasm of left ovary
C79.89 Secondary malignant neoplasm of other specified sites199.0 Disseminated Malignant Neoplasm
C80.0 Disseminated malignant neoplasm, unspecified
C45.9 Mesothelioma, unspecified
C80.1 Malignant (primary) neoplasm, unspecified
C82.57 Diffuse follicle center lymphoma, spleen
C84.97 Mature T/NK cell lymphomas, unspecified, spleen
C84.A7 Cutaneous T cell lymphoma, unspecified, spleen
C84.Z7 Other mature T/NK cell lymphomas, spleen
C85.17 Unspecified B cell lymphoma, spleen
C85.27 Mediastinal (thymic) large B cell lymphoma, spleen
C85.87 Other specified types of non Hodgkin lymphoma, spleen
C85.97 Non Hodgkin lymphoma, unspecified, spleen
C86.1 Hepatosplenic T cell lymphoma (Alpha beta and gamma delta types)
D01.5 Carcinoma in situ of liver, gallbladder and bile ducts
D01.7 Carcinoma in situ of other specified digestive organs
D01.9 Carcinoma in situ of digestive organ, unspecified
D02.21 Carcinoma in situ of right bronchus and lung
D02.22 Carcinoma in situ of left bronchus and lung
D49.0 Neoplasm of unspecified behavior of digestive system
D49.1 Neoplasm of unspecified behavior of respiratory system
D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin
D49.3 Neoplasm of unspecified behavior of breast
D49.4 Neoplasm of unspecified behavior of bladder
D49.511: Neoplasm of unspecified behavior of right kidney
D49.512: Neoplasm of unspecified behavior of left kidney
D49.519: Neoplasm of unspecified behavior of unspecified kidney
D49.59: Neoplasm of unspecified behavior of other genitourinary organ
D49.6 Neoplasm of unspecified behavior of brain
D49.7 Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system
D49.89 Neoplasm of unspecified behavior of other specified sites
D49.9 Neoplasm of unspecified behavior of unspecified site
J91.0 Malignant pleural effusion

84999Afirma Thyroid FNA

Afirma Thyroid FNA is considered medically necessary and, therefore, covered for individuals with the following conditions:

  • With one or more thyroid nodules with a history or characteristics suggesting malignancy such as:
    • Nodule growth over time
    • Family history of thyroid cancer
    • Hoarseness, difficulty swallowing or breathing
    • History of exposure to ionizing radiation
    • Hard nodule compared with rest of gland consistency
    • Presence of cervical adenopathy
  • Have an indeterminate follicular pathology on fine needle aspiration

The following ICD-10 codes are the diagnosis codes covered for Afirma when reported with Unlisted code 84999 (Unlisted molecular pathology procedure):

D34 Benign neoplasm of thyroid gland
D44.0 Neoplasm of uncertain behavior of thyroid gland
D44.9 Neoplasm of uncertain behavior of unspecified endocrine gland
E01.0 Iodine deficiency related diffuse (endemic) goiter
E01.1 Iodine deficiency related multinodular (endemic) goiter
E01.2 Idodine deficiency related (endemic) goiter, unspecified
E04.0 Nontoxic diffuse goiter
E04.1 Nontoxic single thyroid nodule
E04.2 Nontoxic multinodular goiter
E04.8 Other specified nontoxic goiter
E04.9 Nontoxic goiter, unspecified

81479 Cobas EGFR Mutation Test

Cobas EGFR Mutation Test is considered medically necessary and, therefore, covered for the following ICD-10 diagnosis codes when this test is reported with Unlisted code 81479 (Unlisted molecular pathology procedure):

C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
C34.2 Malignant neoplasm of middle lobe, bronchus or lung
C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
C34.91 Malignant neoplasm of unspecified part of right bronchus or lung
C34.92 Malignant neoplasm of unspecified part of left bronchus or lung

84999 Cobas 4800 BRAF V600 Test

Cobas 4800 BRAF V600 Test is considered medically necessary and, therefore, covered for the following ICD-10 diagnosis codes when this test is reported with Unlisted code 84999 (Unlisted molecular pathology procedure):

C42.62 Malignant melanoma of left upper limb, including shoulder
C43.0 Malignant melanoma of lip
C43.111 Malignant melanoma of right upper eyelid, including canthus
C43.112 Malignant melanoma of right lower eyelid, including canthus
C43.121 Malignant melanoma of left upper eyelid, including canthus
C43.122 Malignant melanoma of left lower eyelid, including canthus
C43.21 Malignant melanoma of right ear and external auricular canal
C43.22 Malignant melanoma of left ear and external auricular canal
C43.31 Malignant melanoma of nose
C43.39 Malignant melanoma of other parts of face
C43.4 Malignant melanoma of scalp and neck
C43.51 Malignant melanoma of anal skin
C43.52 Malignant melanoma of skin of breast
C43.59 Malignant melanoma of other part of trunk
C43.61 Malignant melanoma of right upper limb, including shoulder
C43.71 Malignant melanoma of right lower limb, including hip
C43.72 Malignant melanoma of left lower limb, including hip
C43.8 Malignant melanoma of overlapping sites of skin
C43.9 Malignant melanoma of skin, unspecified
C79.2 Secondary malignant neoplasm of skin
D03.0 Melanoma in situ of lip
D03.111 Melanoma in situ of right upper eyelid, including canthus
D03.112 Melanoma in situ of right lower eyelid, including canthus
D03.121 Melanoma in situ of left upper eyelid, including canthus
D03.122 Melanoma in situ of left lower eyelid, including canthus
D03.21 Melanoma in situ of right ear and external auricular canal
D03.22 Melanoma in situ of left ear and external auricular canal
D03.39 Melanoma in situ of other parts of face
D03.4 Melanoma in situ of scalp and neck
D03.51 Melanoma in situ of anal skin
D03.52 Melanoma in situ of breast (skin) (soft tissue)
D03.59 Melanoma in situ of other part of trunk
D03.61 Melanoma in situ of right upper limb, including shoulder
D03.62 Melanoma in situ of left upper limb, including shoulder
D03.71 Melanoma in situ of right lower limb, including hip
D03.72 Melanoma in situ of left lower limb, including hip
D03.8 Melanoma in situ of other sites
D03.9 Melanoma in situ, unspecified

81479Breakpoint testing for BCR-ABL1 as a combination or panel of tests is considered medically necessary and, therefore, covered as a diagnostic test for the following indications:
  • Acute lymphoid leukemia (ALL)
  • Myeloproliferative diseases [MPD - essential thrombocytosis (ET), myelofibrosis & polycythemia vera (PV)]
  • Chronic myeloid leukemia (CML) and chronic myelomonocytic leukemia (CMML)
84999Progensa PCA3 Assay

PCA3 testing is medically necessary and , therefore, covered only when all biopsies in previous encounter(s) are negative and when the patient or physician wants to avoid repeat biopsy (watchful waiting), and for the following ICD-10 diagnosis codes when Progensa PCA3 is reported with Unlisted code 84999 (Unlisted molecular pathology procedure):

D29.1 Benign neoplasm of prostate
D40.0 Neoplasm of uncertain behavior of prostate
N40.0 Enlarged prostate without lower urinary tract symptoms
N40.2 Nodular prostate without lower urinary tract symptoms
N40.3 Nodular prostate with lower urinary tract symptoms
N41.0 Acute prostatitis
N42.9 Disorder of prostate, unspecified
R31.1 Benign essential microscopic hematuria
R31.21: Asymptomatic microscopic hematuria
R31.29: Other microscopic hematuria
R35.1 Nocturia
R39.12 Poor urinary stream
R39.14 Feeling of incomplete bladder emptying
R97.20: Elevated prostate specific antigen [PSA]
R97.21: Rising PSA following treatment for malignant neoplasm of prostate

84999Vectra DA

Vectra DA is considered medically necessary and, therefore, covered for the following ICD-10 diagnosis codes when this test is reported with Unlisted code 84999 (Unlisted molecular pathology procedure):

M05.011 Felty's syndrome, right shoulder
M05.012 Felty's syndrome, left shoulder
M05.021 Felty's syndrome, right elbow
M05.022 Felty's syndrome, left elbow
M05.031 Felty's syndrome, right wrist
M05.032 Felty's syndrome, left wrist
M05.041 Felty's syndrome, right hand
M05.042 Felty's syndrome, left hand
M05.051 Felty's syndrome, right hip
M05.052 Felty's syndrome, left hip
M05.061 Felty's syndrome, right knee
M05.062 Felty's syndrome, left knee M05.071 Felty's syndrome, right ankle and foot
M05.072 Felty's syndrome, left ankle and foot
M05.09 Felty's syndrome, multiple sites
M05.111 Rheumatoid lung disease with rheumatoid arthritis of right shoulder
M05.112 Rheumatoid lung disease with rheumatoid arthritis of left shoulder
M05.121 Rheumatoid lung disease with rheumatoid arthritis of right elbow
M05.122 Rheumatoid lung disease with rheumatoid arthritis of left elbow
M05.131 Rheumatoid lung disease with rheumatoid arthritis of right wrist
M05.132 Rheumatoid lung disease with rheumatoid arthritis of left wrist
M05.141 Rheumatoid lung disease with rheumatoid arthritis of right hand
M05.142 Rheumatoid lung disease with rheumatoid arthritis of left hand
M05.151 Rheumatoid lung disease with rheumatoid arthritis of right hip
M05.152 Rheumatoid lung disease with rheumatoid arthritis of left hip
M05.161 Rheumatoid lung disease with rheumatoid arthritis of right knee
M05.162 Rheumatoid lung disease with rheumatoid arthritis of left knee
M05.171 Rheumatoid lung disease with rheumatoid arthritis of right ankle and foot
M05.172 Rheumatoid lung disease with rheumatoid arthritis of left ankle and foot
M05.19 Rheumatoid lung disease with rheumatoid arthritis of multiple sites
M05.211 Rheumatoid vasculitis with rheumatoid arthritis of right shoulder
M05.212 Rheumatoid vasculitis with rheumatoid arthritis of left shoulder
M05.221 Rheumatoid vasculitis with rheumatoid arthritis of right elbow
M05.222 Rheumatoid vasculitis with rheumatoid arthritis of left elbow
M05.231 Rheumatoid vasculitis with rheumatoid arthritis of right wrist
M05.232 Rheumatoid vasculitis with rheumatoid arthritis of left wrist
M05.241 Rheumatoid vasculitis with rheumatoid arthritis of right hand
M05.242 Rheumatoid vasculitis with rheumatoid arthritis of left hand
M05.251 Rheumatoid vasculitis with rheumatoid arthritis of right hip
M05.252 Rheumatoid vasculitis with rheumatoid arthritis of left hip
M05.261 Rheumatoid vasculitis with rheumatoid arthritis of right knee
M05.262 Rheumatoid vasculitis with rheumatoid arthritis of left knee
M05.271 Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot
M05.272 Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot
M05.29 Rheumatoid vasculitis with rheumatoid arthritis of multiple sites
M05.311 Rheumatoid heart disease with rheumatoid arthritis of right shoulder
M05.312 Rheumatoid heart disease with rheumatoid arthritis of left shoulder
M05.321 Rheumatoid heart disease with rheumatoid arthritis of right elbow
M05.322 Rheumatoid heart disease with rheumatoid arthritis of left elbow
M05.331 Rheumatoid heart disease with rheumatoid arthritis of right wrist
M05.332 Rheumatoid heart disease with rheumatoid arthritis of left wrist M05.341 Rheumatoid heart disease with rheumatoid arthritis of right hand
M05.342 Rheumatoid heart disease with rheumatoid arthritis of left hand
M05.351 Rheumatoid heart disease with rheumatoid arthritis of right hip
M05.352 Rheumatoid heart disease with rheumatoid arthritis of left hip
M05.361 Rheumatoid heart disease with rheumatoid arthritis of right knee
M05.362 Rheumatoid heart disease with rheumatoid arthritis of left knee
M05.371 Rheumatoid heart disease with rheumatoid arthritis of right ankle and foot
M05.372 Rheumatoid heart disease with rheumatoid arthritis of left ankle and foot
M05.39 Rheumatoid heart disease with rheumatoid arthritis of multiple sites
M05.411 Rheumatoid myopathy with rheumatoid arthritis of right shoulder
M05.412 Rheumatoid myopathy with rheumatoid arthritis of left shoulder
M05.421 Rheumatoid myopathy with rheumatoid arthritis of right elbow
M05.422 Rheumatoid myopathy with rheumatoid arthritis of left elbow
M05.431 Rheumatoid myopathy with rheumatoid arthritis of right wrist
M05.432 Rheumatoid myopathy with rheumatoid arthritis of left wrist
M05.441 Rheumatoid myopathy with rheumatoid arthritis of right hand
M05.442 Rheumatoid myopathy with rheumatoid arthritis of left hand
M05.451 Rheumatoid myopathy with rheumatoid arthritis of right hip
M05.452 Rheumatoid myopathy with rheumatoid arthritis of left hip
M05.461 Rheumatoid myopathy with rheumatoid arthritis of right knee
M05.462 Rheumatoid myopathy with rheumatoid arthritis of left knee
M05.471 Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot
M05.472 Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot
M05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sites
M05.511 Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder
M05.512 Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder
M05.521 Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow
M05.522 Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow
M05.531 Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist
M05.532 Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist
M05.541 Rheumatoid polyneuropathy with rheumatoid arthritis of right hand
M05.542 Rheumatoid polyneuropathy with rheumatoid arthritis of left hand
M05.551 Rheumatoid polyneuropathy with rheumatoid arthritis of right hip
M05.552 Rheumatoid polyneuropathy with rheumatoid arthritis of left hip
M05.561 Rheumatoid polyneuropathy with rheumatoid arthritis of right knee
M05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of left knee
M05.571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot
M05.572 Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot
M05.59 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
M05.611 Rheumatoid arthritis of right shoulder with involvement of other organs and systems
M05.612 Rheumatoid arthritis of left shoulder with involvement of other organs and systems
M05.621 Rheumatoid arthritis of right elbow with involvement of other organs and systems
M05.622 Rheumatoid arthritis of left elbow with involvement of other organs and systems
M05.631 Rheumatoid arthritis of right wrist with involvement of other organs and systems
M05.632 Rheumatoid arthritis of left wrist with involvement of other organs and systems
M05.641 Rheumatoid arthritis of right hand with involvement of other organs and systems
M05.642 Rheumatoid arthritis of left hand with involvement of other organs and systems
M05.651 Rheumatoid arthritis of right hip with involvement of other organs and systems
M05.652 Rheumatoid arthritis of left hip with involvement of other organs and systems
M05.661 Rheumatoid arthritis of right knee with involvement of other organs and systems
M05.662 Rheumatoid arthritis of left knee with involvement of other organs and systems
M05.671 Rheumatoid arthritis of right ankle and foot with involvement of other organs and systems
M05.672 Rheumatoid arthritis of left ankle and foot with involvement of other organs and systems
M05.69 Rheumatoid arthritis of multiple sites with involvement of other organs and systems
M05.711 Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement
M05.712 Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement
M05.721 Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement
M05.722 Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement
M05.731 Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement
M05.732 Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement
M05.741 Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement
M05.742 Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement
M05.751 Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement
M05.752 Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement
M05.761 Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement
M05.762 Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement
M05.771 Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement
M05.772 Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement
M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement
M05.811 Other rheumatoid arthritis with rheumatoid factor of right shoulder
M05.812 Other rheumatoid arthritis with rheumatoid factor of left shoulder
M05.821 Other rheumatoid arthritis with rheumatoid factor of right elbow
M05.822 Other rheumatoid arthritis with rheumatoid factor of left elbow
M05.831 Other rheumatoid arthritis with rheumatoid factor of right wrist
M05.832 Other rheumatoid arthritis with rheumatoid factor of left wrist
M05.841 Other rheumatoid arthritis with rheumatoid factor of right hand
M05.842 Other rheumatoid arthritis with rheumatoid factor of left hand
M05.851 Other rheumatoid arthritis with rheumatoid factor of right hip
M05.852 Other rheumatoid arthritis with rheumatoid factor of left hip
M05.861 Other rheumatoid arthritis with rheumatoid factor of right knee
M05.862 Other rheumatoid arthritis with rheumatoid factor of left knee
M05.871 Other rheumatoid arthritis with rheumatoid factor of right ankle and foot
M05.872 Other rheumatoid arthritis with rheumatoid factor of left ankle and foot
M05.89 Other rheumatoid arthritis with rheumatoid factor of multiple sites
M06.011 Rheumatoid arthritis without rheumatoid factor, right shoulder
M06.012 Rheumatoid arthritis without rheumatoid factor, left shoulder
M06.021 Rheumatoid arthritis without rheumatoid factor, right elbow
M06.022 Rheumatoid arthritis without rheumatoid factor, left elbow
M06.031 Rheumatoid arthritis without rheumatoid factor, right wrist
M06.032 Rheumatoid arthritis without rheumatoid factor, left wrist
M06.041 Rheumatoid arthritis without rheumatoid factor, right hand
M06.042 Rheumatoid arthritis without rheumatoid factor, left hand
M06.051 Rheumatoid arthritis without rheumatoid factor, right hip
M06.052 Rheumatoid arthritis without rheumatoid factor, left hip
M06.061 Rheumatoid arthritis without rheumatoid factor, right knee
M06.062 Rheumatoid arthritis without rheumatoid factor, left knee
M06.071 Rheumatoid arthritis without rheumatoid factor, right ankle and foot
M06.072 Rheumatoid arthritis without rheumatoid factor, left ankle and foot
M06.08 Rheumatoid arthritis without rheumatoid factor, vertebrae
M06.09 Rheumatoid arthritis without rheumatoid factor, multiple sites
M06.1 Adult onset Still's disease
M06.211 Rheumatoid bursitis, right shoulder
M06.212 Rheumatoid bursitis, left shoulder
M06.221 Rheumatoid bursitis, right elbow
M06.222 Rheumatoid bursitis, left elbow
M06.231 Rheumatoid bursitis, right wrist
M06.232 Rheumatoid bursitis, left wrist
M06.241 Rheumatoid bursitis, right hand
M06.242 Rheumatoid bursitis, left hand
M06.251 Rheumatoid bursitis, right hip
M06.252 Rheumatoid bursitis, left hip
M06.261 Rheumatoid bursitis, right knee
M06.262 Rheumatoid bursitis, left knee
M06.271 Rheumatoid bursitis, right ankle and foot
M06.272 Rheumatoid bursitis, left ankle and foot
M06.28 Rheumatoid bursitis, vertebrae
M06.29 Rheumatoid bursitis, multiple sites
M06.311 Rheumatoid nodule, right shoulder
M06.312 Rheumatoid nodule, left shoulder
M06.321 Rheumatoid nodule, right elbow
M06.322 Rheumatoid nodule, left elbow
M06.331 Rheumatoid nodule, right wrist
M06.332 Rheumatoid nodule, left wrist
M06.341 Rheumatoid nodule, right hand
M06.342 Rheumatoid nodule, left hand
M06.351 Rheumatoid nodule, right hip
M06.352 Rheumatoid nodule, left hip
M06.361 Rheumatoid nodule, right knee
M06.362 Rheumatoid nodule, left knee
M06.371 Rheumatoid nodule, right ankle and foot
M06.372 Rheumatoid nodule, left ankle and foot
M06.38 Rheumatoid nodule, vertebrae
M06.39 Rheumatoid nodule, multiple sites
M06.811 Other specified rheumatoid arthritis, right shoulder
M06.812 Other specified rheumatoid arthritis, left shoulder
M06.821 Other specified rheumatoid arthritis, right elbow
M06.822 Other specified rheumatoid arthritis, left elbow
M06.831 Other specified rheumatoid arthritis, right wrist
M06.832 Other specified rheumatoid arthritis, left wrist
M06.841 Other specified rheumatoid arthritis, right hand
M06.842 Other specified rheumatoid arthritis, left hand
M06.851 Other specified rheumatoid arthritis, right hip
M06.852 Other specified rheumatoid arthritis, left hip
M06.861 Other specified rheumatoid arthritis, right knee
M06.862 Other specified rheumatoid arthritis, left knee
M06.871 Other specified rheumatoid arthritis, right ankle and foot
M06.872 Other specified rheumatoid arthritis, left ankle and foot
M06.88 Other specified rheumatoid arthritis, vertebrae
M06.89 Other specified rheumatoid arthritis, multiple sites

81479Therascreen KRAS PCR Kit

Therascreen KRAS PCR Kit is considered medically necessary and, therefore, covered for the following ICD-10 diagnosis codes when this test is reported with Unlisted code 81479 (Unlisted molecular pathology procedure):

C77.0 Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck
C77.1 Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes
C77.2 Secondary and unspecified malignant neoplasm of intra abdominal lymph nodes
C77.3 Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes
C77.4 Secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes
C77.5 Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes
C77.8 Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions
C77.9 Secondary and unspecified malignant neoplasm of lymph node, unspecified
C78.01 Secondary malignant neoplasm of right lung
C78.02 Secondary malignant neoplasm of left lung
C78.1 Secondary malignant neoplasm of mediastinum
C78.2 Secondary malignant neoplasm of pleura
C78.39 Secondary malignant neoplasm of other respiratory organs
C78.4 Secondary malignant neoplasm of small intestine
C78.5 Secondary malignant neoplasm of large intestine and rectum
C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct
C78.80 Secondary malignant neoplasm of unspecified digestive organ
C78.89 Secondary malignant neoplasm of other digestive organs
C79.01 Secondary malignant neoplasm of right kidney and renal pelvis
C79.02 Secondary malignant neoplasm of left kidney and renal pelvis
C79.11 Secondary malignant neoplasm of bladder
C79.19 Secondary malignant neoplasm of other urinary organs
C79.2 Secondary malignant neoplasm of skin
C79.31 Secondary malignant neoplasm of brain
C79.49 Secondary malignant neoplasm of other parts of nervous system
C79.32 Secondary malignant neoplasm of cerebral meninges
C79.49 Secondary malignant neoplasm of other parts of nervous system
C79.51 Secondary malignant neoplasm of bone
C79.52 Secondary malignant neoplasm of bone marrow
C79.61 Secondary malignant neoplasm of right ovary
C79.62 Secondary malignant neoplasm of left ovary
C79.71 Secondary malignant neoplasm of right adrenal gland
C79.72 Secondary malignant neoplasm of left adrenal gland
C79.81 Secondary malignant neoplasm of breast
C79.82 Secondary malignant neoplasm of genital organs
C79.89 Secondary malignant neoplasm of other specified sites

84999ThxID BRAF Test

ThxID BRAF Test is considered medically necessary and, therefore, covered for the following ICD-10 diagnosis codes when this test is reported with Unlisted code 84999 (Unlisted molecular pathology procedure): :

C42.62 Malignant melanoma of left upper limb, including shoulder
C43.0 Malignant melanoma of lip
C43.111 Malignant melanoma of right upper eyelid, including canthus
C43.112 Malignant melanoma of right lower eyelid, including canthus
C43.121 Malignant melanoma of left upper eyelid, including canthus
C43.122 Malignant melanoma of left lower eyelid, including canthus
C43.21 Malignant melanoma of right ear and external auricular canal
C43.22 Malignant melanoma of left ear and external auricular canal
C43.31 Malignant melanoma of nose
C43.39 Malignant melanoma of other parts of face
C43.4 Malignant melanoma of scalp and neck
C43.51 Malignant melanoma of anal skin
C43.52 Malignant melanoma of skin of breast
C43.59 Malignant melanoma of other part of trunk
C43.61 Malignant melanoma of right upper limb, including shoulder
C43.71 Malignant melanoma of right lower limb, including hip
C43.72 Malignant melanoma of left lower limb, including hip
C43.8 Malignant melanoma of overlapping sites of skin
C43.9 Malignant melanoma of skin, unspecified
D03.0 Melanoma in situ of lip
D03.111 Melanoma in situ of right upper eyelid, including canthus
D03.112 Melanoma in situ of right lower eyelid, including canthus
D03.121 Melanoma in situ of left upper eyelid, including canthus
D03.122 Melanoma in situ of left lower eyelid, including canthus
D03.21 Melanoma in situ of right ear and external auricular canal
D03.22 Melanoma in situ of left ear and external auricular canal
D03.39 Melanoma in situ of other parts of face
D03.4 Melanoma in situ of scalp and neck
D03.51 Melanoma in situ of anal skin
D03.52 Melanoma in situ of breast (skin) (soft tissue)
D03.59 Melanoma in situ of other part of trunk
D03.61 Melanoma in situ of right upper limb, including shoulder
D03.62 Melanoma in situ of left upper limb, including shoulder
D03.71 Melanoma in situ of right lower limb, including hip
D03.72 Melanoma in situ of left lower limb, including hip
D03.8 Melanoma in situ of other sites
D03.9 Melanoma in situ, unspecified

81479Therascreen EGFR RGQ PCR Kit

Therascreen EGFR RGQ PCR Kit is considered medically necessary and, therefore, covered for the following ICD-10 diagnosis codes when this test is reported with Unlisted code 81479 (Unlisted molecular pathology procedure):

C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
C34.2 Malignant neoplasm of middle lobe, bronchus or lung
C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
C34.91 Malignant neoplasm of unspecified part of right bronchus or lung
C34.92 Malignant neoplasm of unspecified part of left bronchus or lung

84999Avise PG Assay

Avise PG is considered medically necessary and, therefore, covered for the following ICD-10 diagnosis codes when this assay is reported with Unlisted code 84999 (Unlisted molecular pathology procedure):

M05.40 Rheumatoid myopathy with rheumatoid arthritis of unspecified site
M05.411 Rheumatoid myopathy with rheumatoid arthritis of right shoulder
M05.412 Rheumatoid myopathy with rheumatoid arthritis of left shoulder
M05.419 Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder
M05.421 Rheumatoid myopathy with rheumatoid arthritis of right elbow
M05.422 Rheumatoid myopathy with rheumatoid arthritis of left elbow
M05.429 Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow
M05.431 Rheumatoid myopathy with rheumatoid arthritis of right wrist
M05.432 Rheumatoid myopathy with rheumatoid arthritis of left wrist
M05.439 Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist
M05.441 Rheumatoid myopathy with rheumatoid arthritis of right hand
M05.442 Rheumatoid myopathy with rheumatoid arthritis of left hand
M05.449 Rheumatoid myopathy with rheumatoid arthritis of unspecified hand
M05.451 Rheumatoid myopathy with rheumatoid arthritis of right hip
M05.452 Rheumatoid myopathy with rheumatoid arthritis of left hip
M05.459 Rheumatoid myopathy with rheumatoid arthritis of unspecified hip
M05.461 Rheumatoid myopathy with rheumatoid arthritis of right knee
M05.462 Rheumatoid myopathy with rheumatoid arthritis of left knee
M05.469 Rheumatoid myopathy with rheumatoid arthritis of unspecified knee
M05.471 Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot
M05.472 Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot
M05.479 Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot
M05.50 – Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site
M05.511 Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder
M05.512 Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder
M05.519 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder
M05.521 Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow
M05.522 Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow
M05.529 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow
M05.531 Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist
M05.532 Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist
M05.539 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist
M05.541 Rheumatoid polyneuropathy with rheumatoid arthritis of right hand
M05.542 Rheumatoid polyneuropathy with rheumatoid arthritis of left hand
M05.549 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand
M05.551 Rheumatoid polyneuropathy with rheumatoid arthritis of right hip
M05.552 Rheumatoid polyneuropathy with rheumatoid arthritis of left hip
M05.559 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip
M05.561 Rheumatoid polyneuropathy with rheumatoid arthritis of right knee
M05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of left knee
M05.569 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee
M05.571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot
M05.572 Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot
M05.579 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot
M05.59 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites

AND one of following ICD-10 codes to indicate methotrexate use for Avise PG when reported with Unlisted code 84999 (Unlisted molecular pathology procedure):

Z92.21 Personal history of antineoplastic chemotherapy
Z92.29 Personal history of other drug therapy

84999HERmark Assay

HERmark Assay is considered medically necessary and, therefore, covered for the following ICD-10 diagnosis codes when this assay is reported with Unlisted code 84999 (Unlisted molecular pathology procedure):

C50.011 Malignant neoplasm of nipple and areola, right female breast
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.211 Malignant neoplasm of upper inner quadrant of right female breast
C50.212 Malignant neoplasm of upper inner quadrant of left female breast
C50.311 Malignant neoplasm of lower inner quadrant of right female breast
C50.312 Malignant neoplasm of lower inner quadrant of left female breast
C50.411 Malignant neoplasm of upper outer quadrant of right female breast
C50.412 Malignant neoplasm of upper outer quadrant of left female breast
C50.511 Malignant neoplasm of lower outer quadrant of right female breast
C50.512 Malignant neoplasm of lower outer quadrant of left female breast
C50.611 Malignant neoplasm of axillary tail of right female breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.811 Malignant neoplasm of other specified sites of right female breast
C50.812 Malignant neoplasm of other specified sites of left female breast
C50.911 Malignant neoplasm of unspecified site of right female breast
C50.912 Malignant neoplasm of unspecified site of left female breast
C50.021 Malignant neoplasm of nipple and areola, right male breast
C50.022 Malignant neoplasm of nipple and areola, left male breast
C50.121 Malignant neoplasm of central portion of right male breast
C50.122 Malignant neoplasm of central portion of left male breast
C50.221 Malignant neoplasm of upper inner quadrant of right male breast
C50.222 Malignant neoplasm of upper inner quadrant of left male breast
C50.321 Malignant neoplasm of lower inner quadrant of right male breast
C50.322 Malignant neoplasm of lower inner quadrant of left male breast
C50.421 Malignant neoplasm of upper outer quadrant of right male breast
C50.422 Malignant neoplasm of upper outer quadrant of left male breast
C50.521 Malignant neoplasm of lower outer quadrant of right male breast
C50.522 Malignant neoplasm of lower outer quadrant of left male breast
C50.621 Malignant neoplasm of axillary tail of right male breast
C50.622 Malignant neoplasm of axillary tail of left male breast
C50.821 Malignant neoplasm of overlapping sites of right male breast
C50.822 Malignant neoplasm of overlapping sites of left male breast
C50.921 Malignant neoplasm of unspecified site of right male breast
C50.922 Malignant neoplasm of unspecified site of left male breast
C79.81 Secondary malignant neoplasm of breast

84999Corus CAD is considered medically necessary and, therefore, covered when at least one diagnosis from the following tables should be present:

I. Typical Symptoms: Identifying appropriate patients for Corus® CAD
    I20.1 Angina pectoris with documented spasm
    I20.8 Other forms of angina pectoris
    I20.9 Angina pectoris, unspecified
    R06.02 Shortness of breath
    R07.2 Precordial pain
    R07.82 Intercostal pain
    R07.89 Other chest pain
    R07.9 Chest pain, unspecified

II. Atypical Symptoms: Require at least one CAD risk factor from III


    M54.9 Dorsalgia, unspecified
    M79.602 Pain in left arm
    M79.622 Pain in left upper arm
    R00.2 Palpitations
    R10.9 Unspecified abdominal pain
    R11.0 Nausea
    R11.2 Nausea with vomiting, unspecified
    R12 Heartburn
    R42 Dizziness and giddiness
    R53.81 Other malaise
    R68.84 Jaw pain

III. Common CAD Risk Factors: Patient must have at least one atypical symptom listed in II in addition to at least one risk factor in list III

E66.9 Obesity, unspecified
E78.00: Pure hypercholesterolemia, unspecified
E78.01: Familial hypercholesterolemia
E78.1 Pure hyperglyceridemia
E78.2 Mixed hyperlipidemia
E78.41 Elevated Lipoprotein(a)
E78.49 Other hyperlipidemia
E78.5 Hyperlipidemia, unspecified
E88.81 Metabolic syndrome
F17.200 Nicotine dependence, unspecified uncomplicated
F17.201 Nicotine dependence unspecified, in remission
F17.210 Nicotine dependence, cigarettes, uncomplicated
F17.211 Nicotine dependence, cigarettes, in remission
F17.220 Nicotine dependence, chewing tobacco, uncomplicated
F17.221 Nicotine dependence, chewing tobacco, in remission
F17.290 Nicotine dependence, other tobacco product, uncomplicated
F17.291 Nicotine dependence, other tobacco product, in remission
I10 Essential (primary) hypertension
I25.111 Atherosclerosis heart disease of native coronary artery with angina pectoris with documented spasm
I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
I65.21 Occlusion and stenosis of right carotid artery
I65.22 Occlusion and stenosis of left carotid artery
I65.23 Occlusion and stenosis of bilateral carotid artery
I67.2 Cerebral atherosclerosis
I70.1 Atherosclerosis of the renal artery
I70.201 Unspecified atherosclerosis of native arteries of the extremities, right leg
I70.202 Unspecified atherosclerosis of native arteries of extremities, left leg
I70.203 Unspecified atherosclerosis of native arteries of extremities, bilateral legs
I70.208 Unspecified atherosclerosis of native arteries of extremities, other extremity
I70.209 Unspecified atherosclerosis of native arteries of extremities, unspecified extremity
Z82.41 Family history of sudden cardiac death
Z82.49 Family history of ischemic heart disease
Z87.891 Personal history of nicotine dependence

81479Rosetta Cancer Origin TestTM (Cancer of the Unknown Primary [CUP]):

Rosetta Cancer Origin TestTM is considered medically necessary and, therefore, covered for providing an important niche in the pathologic diagnosis of cancer of unknown primary when a conventional surgical pathology/imaging work-up is unable to identify a primary neoplastic site.

The following ICD-10 codes are the diagnosis codes covered for ROSETTA CANCER ORIGIN TEST when reported with Unlisted code 81479 (Unlisted molecular pathology procedure):

C80.0 Disseminated malignant neoplasm, unspecified
C80.1 Malignant (primary) neoplasm, unspecified

84999ResponseDX Tissue of Origin®

ResponseDX Tissue of Origin is considered medically necessary and, therefore, covered for the following ICD-10 diagnosis codes when this test is reported with Unlisted code 84999 (Unlisted molecular pathology procedure):

C18.1 Malignant neoplasm of appendix
C18.9 Malignant neoplasm of colon, unspecified
C22.0 Liver cell carcinoma
C22.2 Hepatoblastoma
C22.3 Angiosarcoma of liver
C22.4 Other Sarcomas of liver
C22.7 Other specified carcinomas of liver
C22.8 Malignant neoplasm of liver, primary, unspecified as to type
C22.9 Malignant neoplasm of liver, not specified as primary or secondary
C25.2 Malignant neoplasm of tail of pancreas
C25.7 Malignant neoplasm of other parts of the pancreas
C25.8 Malignant neoplasm of overlapping sites of pancreas
C25.9 Malignant neoplasm of pancreas, unspecified
C33 Malignant neoplasm of trachea
C34.00 Malignant neoplasm of unspecified main bronchus
C34.01 Malignant neoplasm of right main bronchus
C34.02 Malignant neoplasm of left main bronchus
C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung
C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung
C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung
C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
C34.92 Malignant neoplasm of overlapping sites of left bronchus and lung
C43.51 Malignant melanoma of anal skin
C43.52 Malignant melanoma of skin of breast
C43.59 Malignant melanoma of other part of trunk
C45.9 Mesothelioma, unspecified
C47.0 Malignant neoplasm of peripheral nerves of head, face, and neck
C47.9 Malignant neoplasm of peripheral nerves and autonomic nervous system, unspecified
C48.0 Malignant neoplasm of retroperitoneum
C49.0 Malignant neoplasm of connective and soft tissue of head, face, and neck
C49.9 Malignant neoplasm of connective and soft tissue, unspecified
C50.411 Malignant neoplasm of upper outer quadrant of right female breast
C50.419 Malignant neoplasm of upper outer quadrant of left female breast
C50.419 Malignant neoplasm of upper outer quadrant of unspecified female breast
C50.511 Malignant neoplasm of lower outer quadrant of right female breast
C50.512 Malignant neoplasm of lower outer quadrant of left female breast
C50.519 Malignant neoplasm of lower outer quadrant of unspecified female breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.819 Malignant neoplasm of overlapping sites of unspecified female breast
C50.911 Malignant neoplasm of unspecified site of right female breast
C50.912 Malignant neoplasm of unspecified site of left female breast
C50.919 Malignant neoplasm of unspecified site of unspecified female breast
C56.1 Malignant neoplasm of right ovary
C56.2 Malignant neoplasm of left ovary
C56.9 Malignant neoplasm of unspecified ovary
C61 Malignant neoplasm of prostate
C64.1 Malignant neoplasm of right kidney, except renal pelvis
C64.2 Malignant neoplasm of left kidney, expect renal pelvis
C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis
C67.5 Malignant neoplasm of bladder neck
C67.9 Malignant neoplasm of bladder, unspecified
C76.0 Malignant neoplasm of head, face and neck
C77.0 Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck
C77.1 Secondary and unspecified malignant neoplasm of intrapelvia lymph nodes
C77.2 Secondary and unspecified malignant neoplasm of intra abdominal lymph nodes
C77.3 Secondary unspecified malignant neoplasm of axilla and upper limb lymph nodes
C77.4 Secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes
C77.5 Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes
C77.8 Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions
C77.9 Secondary and unspecified malignant neoplasm of lymph node, unspecified
C78.00 Secondary and unspecified malignant neoplasm of unspecified lung
C78.01 Secondary malignant neoplasm of right lung
C78.02 Secondary malignant neoplasm of left lung
C78.5 Secondary malignant neoplasm of large intestine and rectum
C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct
C79.00 Secondary malignant neoplasm of unspecified kidney and renal pelvis
C79.01 Secondary malignant neoplasm of right kidney and renal pelvis
C79.02 Secondary malignant neoplasm of left kidney and renal pevis
C79.2 Secondary malignant neoplasm of skin
C79.31 Secondary malignant neoplasm of brain
C79.51 Secondary malignant neoplasm of bone
C79.52 Secondary malignant neoplasm of bone marrow
C79.60 Secondary malignant neoplasm of unspecified ovary
C79.61 Secondary malignant neoplasm of right ovary
C79.62 Secondary malignant neoplasm of left ovary
C79.89 Secondary malignant neoplasm of other specified sites
C79.9 Secondary malignant neoplasm of unspecified site
C80.0 Disseminated malignant neoplasm, unspecified
C80.1 Malignant (primary) neoplasm, unspecified
C82.57 Diffuse follicle center lymphoma, spleen
C84.97 Mature T/NK cell lymphomas, unspecified, spleen
C84.A7 Cutaneous T cell lymphoma, unspecified, spleen
C85.17 Unspecified B cell lymphoma, spleen
C85.27 Mediastinal (thymic) large B cell lymphoma, spleen
C85.87 Other specified types of non Hodgkin lymphoma, spleen
C85.97 Non Hodgkin lymphoma, unspecified spleen
C86.1 Hepatosplenic T cell lymphoma
D01.5 Carcinoma in situ of liver, gallbladder and bile ducts
D01.7 Carcinoma in situ of other specified digestive oragans
D01.9 Carcinoma in situ of od digestive organ, unspecified
D02.20 Carcinoma in situ of unspecified bronchus and lung
D02.21 Carcinoma in situ of right bronchus and lung
D02.22 Carcinoma in situ of left bronchus and lung
D03.51 Melanoma in situ of anal skin
D03.52 Melanoma in situ of breast (skin) (soft tissue)
D03.59 Melanoma in situ of other part of trunk
D49.0 Neoplasm of unspecified behavior of digestive system
D49.1 Neoplasm of unspecified behavior of respiratory system
D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin
D49.3 Neoplasm of unspecified behavior of breast
D49.4 Neoplasm of unspecified behavior of bladder
D49.511: Neoplasm of unspecified behavior of right kidney
D49.512: Neoplasm of unspecified behavior of left kidney
D49.519: Neoplasm of unspecified behavior of unspecified kidney
D49.59: Neoplasm of unspecified behavior of other genitourinary organ
D49.6 Neoplasm of unspecified behavior of brain
D49.7 Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system
D49.89 Neoplasm of unspecified behavior of other specified sites
D49.9 Neoplasm of unspecified behavior of unspecified sites
J91.0 Malignant pleural effusion


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.
Code
G0452

Miscellaneous
Code
0001U
0005U
0008M
0012U
0016U
0017U
0018U
0022U
0027U
0037U
0040U
0046U
0047U
0048U
0049U
0070U
0071U
0072U
0073U
0074U
0075U
0076U
0084U
0090U
0096U
0098U
0154U
0155U
0500T
81105
81106
81107
81108
81109
81110
81111
81112
81120
81121
81162
81170
81175
81176
81218
81219
81226
81232
81238
81247
81248
81249
81257
81258
81259
81269
81272
81273
81276
81277
81288
81307
81308
81309
81311
81314
81334
81335
81361
81362
81363
81364
81412
81413
81414
81420
81439
81490
81493
81519
81520
81521
81522
81525
81528
81538
81539
81540
81541
81542
81545
81551
81552
81595
87483
87563
87624
87625
87634
87662
87806
88364
88366
G0476
81163
81164
81165
81166
81167
81171
81172
81173
81174
81177
81178
81179
81180
81181
81182
81183
81184
81185
81186
81187
81188
81189
81190
81204
81233
81234
81236
81237
81239
81271
81274
81284
81285
81286
81289
81305
81306
81312
81320
81329
81333
81336
81337
81343
81344
81345
81443
81518




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

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