Commercial

eviCore Lab Management (Independence)
06.02.52s

Policy


This policy does not apply to those members for whom Independence Administrators serve as the claims administrator.


The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

This policy does not apply to self-funded groups for whom eviCore's Lab management Program is not applicable; individual benefits must be verified.​

The intent of this policy is to communicate that the Company has delegated the responsibility for utilization management activities of genetic/genomic tests and certain molecular analyses and cytogenetic tests to CareCore National, LLC d/b/a eviCore healthcare (eviCore), with the exception of services performed in the emergency room or during an inpatient or observation unit stay.

PRE-SERVICE REVIEWS

The Company requires pre-service reviews for certain genetic/genomic tests through CareCore National, LLC d/b/a eviCore healthcare (eviCore), including but not limited to:
  • BRCA gene testing (breast and ovarian cancer syndrome)
  • Lynch syndrome gene testing
  • Cystic fibrosis full gene sequencing and deletion/duplication analyses
  • Select pharmacogenomic testing
  • Genetic Panels (e.g., cancer type panels for colon, breast, or neuroendocrine cancers)
  • Cancer gene expression tests (e.g., OncotypeDX®, MammaPrint®, Afirma® Thyroid Fine-Needle Aspiration [FNA] Analysis)
  • Tumor molecular profiling (e.g., FoundationOne®, neoTYPE™, OncoPlexDX®)
  • Expanded carrier screening panels (e.g., Carrier Status DNA Insight®, Counsyl Family Prep Screen, Pan-Ethnic Carrier Screening)
  • Genome-wide tests (e.g., Microarray studies, Whole exome testing, Whole genome testing, Mitochondrial genome or nuclear testing)

Refer to Attachment A of this policy for a complete list of procedure codes that represent genetic/genomic tests requiring pre-service reviews. In addition to the requirement for pre-service reviews, the procedure codes listed in Attachment A will undergo prepayment reviews.

Genetic/genomic tests, which are listed in Attachment A of this policy, that do not meet coverage criteria may be considered experimental/investigational or not medically necessary, and, therefore, not covered.

PREPAYMENT REVIEWS

All genetic/genomic tests, along with certain molecular analyses (e.g., immunohistochemistry [IHC], morphometric analyses, flow cytometry) and molecular cytogenetic tests (e.g., fluorescent in situ hybridization [FISH], karyotyping), will be reviewed prior to claim payment through CareCore National, LLC d/b/a eviCore healthcare (eviCore).

In addition to the procedure codes in Attachment A, refer to Attachment B of this policy for a list of additional procedure codes that represent laboratory tests that will undergo prepayment reviews. The procedure codes listed in Attachment B do not require pre-service reviews.

Genetic/genomic tests, molecular analyses, and cytogenetic tests, which are listed in Attachment B of this policy, that do not meet coverage criteria may be considered experimental/investigational or not medically necessary, and, therefore, not covered.

EVICORE LAB MANAGEMENT PROGRAM CLINICAL GUIDELINES

eviCore utilizes its Lab Management Program Clinical Guidelines for medical necessity determination related to the delegated genetic/genomic tests and certain molecular analyses and cytogenetic tests.

eviCore's Lab Management Program Clinical Guidelines are available at: https://www.evicore.com/healthplan/IBC.

REQUIRED DOCUMENTATION

The individual’s medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.



Guidelines


BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, genetic/genomic tests, molecular analyses, and cytogenetic tests are covered under the medical benefits of the Company’s products when the medical necessity criteria for the services are met. However, services that are identified as experimental/investigational or not medically necessary are not eligible for coverage or reimbursement by the company.

Procedure codes listed in this policy also continue to be subject to Company claims adjudication logic, eligibility, benefits, limitations, exclusions, referral requirements, provider contracts, and Company policies.


Description


The Company has delegated utilization management of genetic/genomic testing and certain molecular analyses and cytogenetic tests to CareCore National, LLC d/b/a eviCore healthcare (eviCore). This utilization management program through eviCore will encompass pre-service reviews and/or prepayment reviews as follows:
  • Pre-service reviews will be required for certain genetic/genomic tests.
  • All genetic/genomic tests, along with certain molecular analyses and cytogenetic tests, will be reviewed prior to claim payment.

eviCore utilizes its Lab Management Program Clinical Guidelines for medical necessity determinations related to the delegated genetic/genomic tests and certain molecular analyses and cytogenetic tests.

eviCore's Lab Management Program Clinical Guidelines are based on peer-reviewed literature, evidence-based guidelines and recommendations from national and international medical societies, and evidence-based medical research centers, including, but not limited to, the National Comprehensive Cancer Network (NCCN), the American College of Obstetrics and Gynecologists (ACOG), the American College of Medical Genetics (ACMG), the American Society of Human Genetics (ASHG), the European Federation of Neurological Societies (EFNS), the American Academy of Neurology (AAN), the National Society of Genetic Counselors (NSGC), the Society for Assisted Reproductive Technology (SART), the American Society for Reproductive Medicine (ASRM), the American Thoracic Society (ATS), the European Respiratory Society (ERS), and the American Society of Clinical Oncology (ASCO).


References


CareCore National, LLC d/b/a eviCore healthcare. Clinical Guidelines: Lab Management Program. Available at: https://www.evicore.com/healthplan/IBC. Accessed November 10th, 2020.



Coding

CPT Procedure Code Number(s)
See Attachments A and B

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
N/A

HCPCS Level II Code Number(s)
See Attachments A and B

Revenue Code Number(s)
N/A




Coding and Billing Requirements


Policy History

1/1/2021
1/1/2021
Medical Policy Bulletin
Commercial
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No