Code - CPT/HCPCS | Title (Service/Description) | Pre Service Review Required | Type of Pre Service Review Required | Submit Using | Policy or Criteria Link(s) | Comments |
0001U | Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reported | Yes | Prior Approval | Utilization Management Tool- Procedures and DME |
Molecular Testing Vendor Policies
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0002M | Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and alcoholic steatohepatitis (ASH) | Yes | Prior Approval | Utilization Management Tool- Procedures and DME |
Molecular Testing Vendor Policies
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0003M | Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and nonalcoholic steatohepatitis (NASH) | Yes | Prior Approval | Utilization Management Tool- Procedures and DME |
Molecular Testing Vendor Policies
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0004M | Scoliosis, DNA analysis of 53 single nucleotide polymorphisms (SNPs), using saliva, prognostic algorithm reported as a risk score | Yes | Prior Approval | Utilization Management Tool- Procedures and DME |
Molecular Testing Vendor Policies
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0005U | Oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score | Yes | Prior Approval | Utilization Management Tool- Procedures and DME |
Molecular Testing Vendor Policies
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0006M | Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk classifier | Yes | Prior Approval | Utilization Management Tool- Procedures and DME |
Molecular Testing Vendor Policies
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0007M | Oncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor disease index | Yes | Prior Approval | Utilization Management Tool- Procedures and DME |
Molecular Testing Vendor Policies
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0007U | Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in comparison to buccal DNA, per date of service | No | N/A | N/A |
Drug Testing in Pain Management and Substance Use Disorder Treatment
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0008U | Helicobacter pylori detection and antibiotic resistance, DNA, 16S and 23S rRNA, gyrA, pbp1, rdxA and rpoB, next-generation sequencing, formalin-fixed paraffin embedded or fresh tissue or fecal sample, predictive, reported as positive or negative for resistance to clarithromycin, fluoroquinolones, metronidazole, amoxicillin, tetracycline, and rifabutin | No | N/A | N/A |
Molecular Testing Vendor Policies
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0008U | Helicobacter pylori detection and antibiotic resistance, DNA, 16S and 23S rRNA, gyrA, pbp1, rdxA and rpoB, next-generation sequencing, formalin-fixed paraffin embedded or fresh tissue or fecal sample, predictive, reported as positive or negative for resistance to clarithromycin, fluoroquinolones, metronidazole, amoxicillin, tetracycline, and rifabutin | No | N/A | N/A |
Plasma-Based Proteomic Screening in the Management of Pulmonary Nodules
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0009U | Oncology (breast cancer), ERBB2 (HER2) copy number by FISH, tumor cells from formalin fixed paraffin embedded tissue isolated using image-based dielectrophoresis (DEP) sorting, reported as ERBB2 gene amplified or non-amplified | No | N/A | N/A |
Molecular Testing Vendor Policies
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0010U | Infectious disease (bacterial), strain typing by whole genome sequencing, phylogenetic-based report of strain relatedness, per submitted isolate | No | N/A | N/A |
Molecular Testing Vendor Policies
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0011M | Oncology, prostate cancer, mRNA expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR test utilizing blood plasma and urine, algorithms to predict high-grade prostate cancer risk | Yes | Prior Approval | Utilization Management Tool- Procedures and DME |
Molecular Testing Vendor Policies
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0011U | Prescription drug monitoring, evaluation of drugs present by LC-MS/MS, using oral fluid, reported as a comparison to an estimated steady-state range, per date of service including all drug compounds and metabolites | No | N/A | N/A |
Drug Testing in Pain Management and Substance Use Disorder Treatment
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0012M | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma | Yes | Prior Approval | Utilization Management Tool- Procedures and DME |
Molecular Testing Vendor Policies
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0013M | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having recurrent urothelial carcinoma | Yes | Prior Approval | Utilization Management Tool- Procedures and DME |
Molecular Testing Vendor Policies
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0016M | Oncology (bladder), mRNA, microarray gene expression profiling of 219 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like) | Yes | Prior Approval | Utilization Management Tool- Procedures and DME |
Molecular Testing Vendor Policies
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0016U | Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation | No | N/A | N/A |
Molecular Testing Vendor Policies
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0017M | Oncology (diffuse large B-cell lymphoma [DLBCL]), mRNA, gene expression profiling by fluorescent probe hybridization of 20 genes, formalin-fixed paraffinembedded tissue, algorithm reported as cell of origin | Yes | Prior Approval | Utilization Management Tool- Procedures and DME |
Molecular Testing Vendor Policies
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0017U | Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected | No | N/A | N/A |
Molecular Testing Vendor Policies
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0018U | Oncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to high risk of malignancy | Yes | Prior Approval | Utilization Management Tool- Procedures and DME |
Molecular Testing Vendor Policies
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0019U | Oncology, RNA, gene expression by whole transcriptome sequencing, formalin-fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agents | Yes | Prior Approval | Utilization Management Tool- Procedures and DME |
Molecular Testing Vendor Policies
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0021U | Oncology (prostate), detection of 8 autoantibodies (ARF 6, NKX3-1, 5-UTR-BMI1, CEP 164, 3-UTR-Ropporin, Desmocollin, AURKAIP-1, CSNK2A2), multiplexed immunoassay and flow cytometry serum, algorithm reported as risk score | No | N/A | N/A |
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
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0022U | Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence or absence of variants and associated therapy(ies) to consider | Yes | Prior Approval | Utilization Management Tool- Procedures and DME |
Molecular Testing Vendor Policies
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0023U | Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or nondetection of FLT3 mutation and indication for or against the use of midostaurin | No | N/A | N/A |
Molecular Testing Vendor Policies
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