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Molecular Pathology/Molecular Diagnostics/Genetic Testing of 43 UnitedHealthcare Medicare Advantage Policy Guideline Approved 03/13/2019

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MOLECULAR PATHOLOGY/MOLECULAR DIAGNOSTICS/

GENETIC TESTING Guideline Number: MPG210.11 Approval Date: March 13, 2019 Table of Contents Page POLICY SUMMARY .................................................... 1 APPLICABLE CODES ................................................. 4 PURPOSE ............................................................... 22 REFERENCES .......................................................... 22 GUIDELINE HISTORY/REVISION INFORMATION .......... 42 TERMS AND CONDITIONS ........................................ 43 POLICY SUMMARY

Overview This policy overview addresses molecular and genetic tests that have proven efficacy according to CMS, in the diagnosis or treatment of medical conditions, including but not limited to the following:

Hereditary Breast and Ovarian Cancer Anomalies in two genes, BRCA1 and BRCA2, are associated with an increased risk of breast and ovarian cancer. Alterations in BRCA1 and BRCA2 explain many, but not all, of inherited forms of breast and ovarian cancer. With the identification of BRCA1 and BRCA2, it is now possible to test for abnormalities in the genes to provide information on the future risk of cancer and to make important treatment decisions in affected individuals. Approximately five- to

ten-percent of all breast cancers, and a similarly small percentage of ovarian cancers, are attributed to dominantly inherited susceptibility. (See LCDs for Cancer section for specific coverage guidelines.)

Gene expression assays for breast cancer treatment, including but not limited to: Breast Cancer Index (BCI)® Genetic Assay EndoPredict®

MammaPrint®

Oncotype DX™

Oncotype DX DCIS Prosigna™ Breast Cancer Prognostic Gene Signature Assay (See LCDs for Cancer section for specific coverage guidelines.) Hereditary Colorectal and Endometrial Cancer Syndromes Lynch Syndrome (previously denoted as Hereditary Non-Polyposis Colorectal Cancer (HNPCC) syndrome), is an autosomal dominant syndrome that accounts for about 3-5% of colorectal cancer cases. HNPCC syndrome mutations

occur in the following genes: hMLH1, hMSH2, hMSH6, PMS2 and EPCAM. Colorectal cancers associated with Lynch

syndrome occur at a younger age (average age of onset between 44-61 years of age) compared with the more common colorectal cancers typically found during the seventh decade of life. Gynecologic cancers may precede colorectal cancer in as many as 50% of female HNPCC gene mutation carriers. (See LCDs for Cancer section for specific coverage guidelines.) Gene Identification, including but not limited to the following genes:

APC BCR/ABL1 BRAF CYP2C19

CYP2D6 EGFR JAK2 KRAS

MGMT MUTYH NRAS

(See LCDs and Articles section for specific coverage guidelines.)

Related Medicare Advantage Policy Guidelines

Clinical Diagnostic Laboratory Services

Corus® CAD (Coronary Artery Disease)

Related Medicare Advantage Coverage Summaries

Genetic Testing

Laboratory Tests and Services

UnitedHealthcare® Medicare Advantage Policy Guideline

Terms and Conditions

See Purpose

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/c/clinical-diagnostic-laboratory-services.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/c/corus-cad-coronary-artery-disease.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/genetic-testing.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/laboratory-tests-services.pdf



Multiple Myeloma Gene Expression Profile MyPRS™ is a test for Multiple Myeloma Gene Expression Profile. Multiple myeloma is an incurable malignancy of terminally differentiated antibody secreting plasma cells. The median overall survival is reported at 3-4 years. Disease sequelae associated with this malignancy includes anemia, immunodeficiency, renal insufficiency/failure, lytic bone

lesions and hypercalcemia. This test is used only after an initial diagnosis of multiple myeloma has been made and will be available to be used in stratification of therapeutic interventions. The coverage is set to include only two clinical settings: Once after initial diagnosis is made, or If relapse has occurred and a change in the therapeutic modalities is contemplated

(See LCDs in Cancer section for coverage guidelines.)

Acute lymphoblastic leukemia (ALL) or multiple myeloma (MM) Sequencing Minimal Residual Disease (MRD) refers to a measure of cancer cells that remain in a person during and following treatment. Testing for MRD using the clonoSEQ® assay is reasonable and necessary when performed on bone marrow specimens in patients with B-Cell acute lymphoblastic leukemia (ALL) or multiple myeloma. (See LCDs in Cancer section for coverage guidelines.)

Loss-of-Heterozygosity Based Topographic Genotyping with PathfinderTG ® /PancraGEN™Test for Pancreatic Cyst/Mass

Combining pathologic study with molecular analyses of microdissected tissue, is claimed to enhance the ability to provide more specific diagnostic information, to help guide treatment decisions. These testing combinations are generally known as topographic genotyping. (See LCD Miscellaneous section for coverage guidelines.) Circulating Tumor Cell (CTC) Assay

CTCs represent the point in the metastatic process of solid tumors when cells from a primary tumor invade, detach, disseminate, colonize and proliferate in a distant site. Detection of elevated CTCs during therapy may be an accurate indication of subsequent rapid disease progression and mortality in breast, colorectal and prostate cancer, noting that FDA labeling includes each of these neoplasms. As a result of limited acceptable study data, CTCs are considered not medically necessary, for all indications. (See LCDs for CTCs for specific coverage guidelines.) Bladder Tumor Markers, including but not limited to:

Bladder Tumor Marker tests include: BTA TRAK®, Nuclear matrix protein 22 (NMP-22), NMP-22 BladderChek®, The UroVysion®, BTA (bladder tumor antigen) stat®, and The ImmunoCyt™. (See LCDs for Cancer section for coverage guidelines.)

NSCLC (non-small cell lung cancer) Testing Guardant360® (Guardant Health, Redwood City, CA), is a plasma-based comprehensive somatic genomic profiling test

(hereafter called CGP) for patients with Stage IIIB/IV non-small cell lung cancer (NSCLC). Plasma-based CGP can help patients avoid an invasive biopsy to obtain tissue for tumor genotyping. (See LCDs for Cancer for coverage guidelines.) Molecular Assays for Prostate Cancer, including but not limited to: ConfirmMDx Decipher®

Oncotype DX™ Prostate Cancer PROGENSA® PCA3 Assay Prolaris™ ProMark® Risk Score (See LCDs for Cancer for coverage guidelines.)

Transplant Recipients

AlloMap® Molecular Expression Testing is a non-invasive gene expression test used to aid in the identification of heart transplant recipients.

AlloSure® donor-derviced cell-free DNA is used to assess the probability of allograft rejection in kidney transplant recipients with clinical suspicion of rejection.

(See LCDs for Molecular Pathology section for coverage guidelines.)

Molecular Pathology Procedures for Human Leukocyte Antigen (HLA) Typing Human Leukocyte Antigen (HLA) typing is performed to assess compatibility of recipients and potential donors as a part of solid organ and hematopoietic stem cell/ bone marrow pretransplant testing. HLA testing is also performed to identify HLA alleles and allele groups (antigen equivalents) associated with specific diseases and individualized responses to drug therapy (e.g., HLA-B*27 and ankylosing spondylitis; HLA-B57:01 and abacavir hypersensitivity; HLA-B*15:02 and carbamazepine, phenytoin or fosphenytoin hypersensitivity), as well as other clinical uses. One or



more HLA genes may be tested in specific clinical situations (e.g., HLA A, B, C,-DRB1, and DQB1 for kidney transplantation). Each HLA gene typically has multiple variant alleles or allele groups that can be identified by typing. (See LCDs for Molecular Pathology for coverage guidelines.)

GeneSight® Assay for Refractory Depression GeneSight Psychotropic is a multiplex pharmacogenomic test involving the analysis of fifty alleles (SNPs) from six different genes. The test results in the differentiation of psychoactive drugs that are likely to be effective and well-tolerated by a particular patient versus those that are not. GeneSight testing may only be ordered by licensed psychiatrists contemplating an alteration in neuropsychiatric medication for patients diagnosed with major depressive disorder (MDD) after at least one prior neuropsychiatric medication failure. (See LCD for GeneSight in Miscellaneous section for coverage guidelines.)

Assays for Rheumatoid Arthritis, including but not limited to: The Avise® PG Assay Vectra® DA (See Article section for coverage guidelines.)

Genetic Testing for Myeloproliferative Disease Myeloproliferative disorders are a group of conditions that cause abnormal growth of blood cells in the bone marrow.

They include polycythemia vera (PV), essential thrombocytosis (ET), primary myelofibrosis (PMF), and chronic myelogenous leukemia (CML). The World Health Organization (WHO) further classifies PV, ET, and PMF as Philadelphia chromosome negative myeloproliferative neoplasms (MPNs). MPNs are characterized by an increase in the number of blood cells. (See LCDs for Molecular Pathology for coverage guidelines.)

Molecular RBC (red blood cell) Phenotyping Molecular RBC Phenotyping is pretransfusion molecular testing using the HEA BeadChip™ assay for the following categories of patients: Long term, frequent transfusions anticipated to prevent the development of alloantibodies (e.g. sickle cell anemia,

thalassemia or other reason); Autoantibodies or other serologic reactivity that impedes the exclusion of clinically significant alloantibodies (e.g.

autoimmune hemolytic anemia, warm autoantibodies, patient recently transfused with a positive DAT, high-titer

low avidity antibodies, patients about to receive or on daratumumab therapy, other reactivity of no apparent cause);

Suspected antibody against an antigen for which typing sera is not available; and Laboratory discrepancies on serologic typing (e.g. rare Rh D antigen variants) (See LCDs for Molecular Pathology

for coverage guidelines.)

Guidelines Based on the Centers for Medicare & Medicaid Services (CMS) Program Integrity Manual (100-08), this policy addresses the circumstances under which the item or service is reasonable and necessary under the Social Security Act, §1862(a)(1)(A). For laboratory services, a service can be reasonable and necessary if the service is safe and effective; and appropriate, including the duration and frequency that is considered appropriate for the item or service, in terms of whether it is furnished in accordance with accepted standards of medical practice for the diagnosis of the patient's condition; furnished in a setting appropriate to the patient's medical needs and condition; ordered and

furnished by qualified personnel; one that meets, but does not exceed, the patient's medical need; and is at least as beneficial as an existing and available medically appropriate alternative. Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review. Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states " ...no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis and treatment of illness or

injury...". Furthermore, it has been longstanding CMS policy that "tests that are performed in the absence of

signs, symptoms, complaints, or personal history of disease or injury are not covered unless explicitly authorized by statute". Screening services, such as pre-symptomatic genetic tests and services, are those used to detect an undiagnosed disease or disease predisposition, and as such are not a Medicare benefit and not covered by Medicare. Similarly, Medicare may not reimburse the costs of tests/examinations that assess the risk for and/or of a condition unless the risk assessment clearly and directly effects the management of the patient. However, Medicare does cover a broad range of legislatively mandated preventive services to prevent disease, detect

disease early when it is most treatable and curable, and manage disease so that complications can be avoided. These services can be found on the CMS website at http://www.cms.gov/PrevntionGenInfo/. Any preventive services and tests whether listed on the CMS Preventive Services webpage or not,are considered non-covered screening (preventive) tests or services which are not a benefit of the Medicare program.

http://www.cms.gov/PrevntionGenInfo/



Per 42 Code of Federal Regulations (CFR) section 410.32 (a) states the following requirements: All diagnostic x-rays tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the

physician who is treating the beneficiary are not reasonable and necessary (see 411.15(k)(1)). Also, see Medicare Benefit Policy Manual (100-02), Chapter 15, Section 80.6 for related physician order instructions. Laboratory services must meet all applicable requirements of the Clinical Laboratory Improvement Amendments of 1988 (CLIA), as set forth at 42 CFR part 493. Section 1862(a)(1)(A) of the Act provides that Medicare payment may not be made for services that are not reasonable and necessary. Clinical laboratory services must be ordered and used promptly by the physician who is treating the beneficiary as described in 42 CFR 410.32(a), or by a qualified

nonphysician practitioner, as described in 42 CFR 410.32(a)(3). Many applications of the molecular pathology procedures are not covered services given lack of benefit category (preventive service) and/or failure to reach the reasonable and necessary threshold for coverage (based on quality of clinical evidence and strength of recommendation). Furthermore, payment of claims in the past (based on stacking codes) or in the future (based on the new code series) is not a statement of coverage since the service was not

audited for compliance with program requirements and documentation supporting the reasonable and necessary testing for the beneficiary. Certain tests and procedures may be subject to prepayment medical review (records

requested) and paid claims must be supportable, if selected, for post payment audit by the MAC or other contractors. Tests for diseases or conditions that manifest severe signs or symptoms in newborns and in early childhood or that result in early death (e.g., Canavan disease) could be subject to automatic denials since these tests are not usually relevant to a Medicare beneficiary.

Documentation Guidelines Documentation must be adequate to verify that coverage guidelines listed above have been met. Thus, the medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed. The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition that warrants the test(s). Examples of documentation requirements of the ordering physician/nonphysician practitioner (NPP) include, but are

not limited to, history and physical or exam findings that support the decision making, problems/diagnoses, relevant data (e.g., lab testing, imaging results). Documentation requirements of the performing laboratory (when requested) include, but are not limited to, lab

accreditation, test requisition, test record/procedures, reports (preliminary and final), and quality control record.

Documentation requirements for lab developed tests/protocols (when requested) include diagnostic test/assay, lab/manufacturer, names of comparable assays/services (if relevant), description of assay, analytical validity evidence, clinical validity evidence, and clinical utility. Providers are required to code to specificity however, if an unlisted CPT code is used the documentation must clearly identify the unique procedure performed. When multiple procedure codes are submitted on a claim (unique and/or unlisted) the documentation supporting each code should be easily identifiable. If on review the contractor cannot link

a billed code to the documentation, these services will be denied based on Title XVIII of the Social Security Act, §1833(e). When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act.

APPLICABLE CODES The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or

guarantee claim payment. Other Policies and Guidelines may apply.

CPT Code Description

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




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)

0002U

Oncology (colorectal), quantitative assessment of three urine metabolites (ascorbic

acid, succinic acid and carnitine) by liquid chromatography with tandem mass spectrometry (LC-MS/MS) using multiple reaction monitoring acquisition, algorithm reported as likelihood of adenomatous polyps

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)

0003U Oncology (ovarian) biochemical assays of five proteins (apolipoprotein A-1, CA 125 II, follicle stimulating hormone, human epididymis protein 4, transferrin), utilizing serum, algorithm reported as a likelihood score

0004M Scoliosis, DNA analysis of 53 single nucleotide polymorphisms (SNPs), using saliva, prognostic algorithm reported as a risk score

0005U Oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score

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

0006U

Prescription drug monitoring, 120 or more drugs and substances, definitive tandem

mass spectrometry with chromatography, urine, qualitative report of presence (including quantitative levels, when detected) or absence of each drug or substance with description and severity of potential interactions, with identified substances, per date of service

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

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

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, predictive, reported as positive or negative for resistance to clarithromycin, fluoroquinolones, metronidazole, amoxicillin, tetracycline and rifabutin

0009M Fetal aneuploidy (trisomy 21, and 18) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy

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

0010U Infectious disease (bacterial), strain typing by whole genome sequencing, phylogenetic-based report of strain relatedness, per submitted isolate

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

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

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 (Effective 04/01/2018)

0012U Germline disorders, gene rearrangement detection by whole genome next-generation sequencing, DNA, whole blood, report of specific gene rearrangement(s)




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 (Effective 04/01/2018)

0013U Oncology (solid organ neoplasia), gene rearrangement detection by whole genome

next-generation sequencing, DNA, fresh or frozen tissue or cells, report of specific gene rearrangement(s)

0014U Hematology (hematolymphoid neoplasia), gene rearrangement detection by whole

genome next-generation sequencing, DNA, whole blood or bone marrow, report of specific gene rearrangement(s)

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

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

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

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

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

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/absence of variants and associated therapy(ies) to consider

0023U Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or non-detection of FLT3 mutation and indication for or against the use of midostaurin

0024U Glycosylated acute phase proteins (GlycA), nuclear magnetic resonance spectroscopy, quantitative (Effective 01/01/2018)

0025U Tenofovir, by liquid chromatography with tandem mass spectrometry (LC-MS/MS), urine, quantitative (Effective 01/01/2018)

0026U

Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical

result ("Positive, high probability of malignancy" or "Negative, low probability of malignancy") (Effective 01/01/2018)

0027U JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15

0029U Drug metabolism (adverse drug reactions and drug response), targeted sequence

analysis (ie, CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs12777823) (Effective 01/01/2018)

0030U Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823) (Effective 01/01/2018)

0031U CYP1A2 (cytochrome P450 family 1, subfamily A, member 2)(eg, drug metabolism) gene analysis, common variants (Effective 01/01/2018)

0032U COMT (catechol-O-methyltransferase)(drug metabolism) gene analysis, c.472G>A (rs4680) variant (Effective 01/01/2018)

0033U HTR2A (5-hydroxytryptamine receptor 2A), HTR2C (5-hydroxytryptamine receptor

2C) (eg, citalopram metabolism) gene analysis, common variants (Effective 01/01/2018)

0034U TPMT (thiopurine S-methyltransferase), NUDT15 (nudix hydroxylase 15)(eg, thiopurine metabolism) gene analysis, common variants (Effective 01/01/2018)




0035U Neurology (prion disease), cerebrospinal fluid, detection of prion protein by quaking-induced conformational conversion, qualitative (Effective 04/01/2018)

0036U Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue

and normal specimen, sequence analyses (Effective 04/01/2018)

0037U

Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324

genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden

0038U Vitamin D, 25 hydroxy D2 and D3, by LC-MS/MS, serum microsample, quantitative (Effective 04/01/2018)

0039U Deoxyribonucleic acid (DNA) antibody, double stranded, high avidity

(Effective 04/01/2018)

0040U BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis, major breakpoint, quantitative (Effective 04/01/2018)

0041U Vitamin D, 25 hydroxy D2 and D3, by LC-MS/MS, serum microsample, quantitative (Effective 04/01/2018)

0042U Borrelia burgdorferi, antibody detection of 12 recombinant protein groups, by immunoblot, IgG (Effective 04/01/2018)

0043U Tick-borne relapsing fever Borrelia group, antibody detection to 4 recombinant protein groups, by immunoblot, IgM (Effective 04/01/2018)

0044U Tick-borne relapsing fever Borrelia group, antibody detection to 4 recombinant protein groups, by immunoblot, IgG (Effective 04/01/2018)

0045U

Oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by real-

time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence score (Effective 07/01/2018)

0046U FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative (Effective 07/01/2018)

0047U Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a risk score (Effective 07/01/2018)

0048U

Oncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons

of 468 cancer-associated genes, including interrogation for somatic mutations and microsatellite instability, matched with normal specimens, utilizing formalin-fixed paraffin-embedded tumor tissue, report of clinically significant mutation(s) (Effective 07/01/2018)

0049U NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative (Effective 07/01/2018)

0050U Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants, copy number variants or rearrangements (Effective 07/01/2018)

0053U Oncology (prostate cancer), FISH analysis of 4 genes (ASAP1, HDAC9, CHD1 and

PTEN), needle biopsy specimen, algorithm reported as probability of higher tumor grade (Effective 07/01/2018)

0055U Cardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotide polymorphism targets and two control targets), plasma

(Effective 07/01/2018)

0056U

Hematology (acute myelogenous leukemia), DNA, whole genome next-generation

sequencing to detect gene rearrangement(s), blood or bone marrow, report of specific gene rearrangement(s) (Effective 07/01/2018)

0057U

Oncology (solid organ neoplasia), mRNA, gene expression profiling by massively

parallel sequencing for analysis of 51 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a normalized percentile rank (Effective 07/01/2018)

0058U Oncology (Merkel cell carcinoma), detection of antibodies to the Merkel cell polyoma virus oncoprotein (small T antigen), serum, quantitative (Effective 07/01/2018)




0059U

Oncology (Merkel cell carcinoma), detection of antibodies to the Merkel cell polyoma

virus capsid protein (VP1), serum, reported as positive or negative (Effective 07/01/2018)

0061U

Transcutaneous measurement of five biomarkers (tissue oxygenation [StO2],

oxyhemoglobin [ctHbO2], deoxyhemoglobin [ctHbR], papillary and reticular dermal hemoglobin concentrations [ctHb1 and ctHb2]), using spatial frequency domain imaging (SFDI) and multi-spectral analysis (Effective 07/01/2018)

0062U Autoimmune (systemic lupus erythematosus), IgG and IgM analysis of 80

biomarkers, utilizing serum, algorithm reported with a risk score (Effective 10/01/2018)

0063U

Neurology (autism), 32 amines by LC-MS/MS, using plasma, algorithm reported as

metabolic signature associated with autism spectrum disorder (Effective 10/01/2018)

0067U

Oncology (breast), immunohistochemistry, protein expression profiling of 4

biomarkers (matrix metalloproteinase-1 [MMP-1], carcinoembryonic antigen-related cell adhesion molecule 6 [CEACAM6], hyaluronoglucosaminidase [HYAL1], highly expressed in cancer protein [HEC1]), formalin-fixed paraffin-embedded precancerous breast tissue, algorithm reported as carcinoma risk score (Effective 10/01/2018)

0069U Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p,

formalin-fixed paraffin-embedded tissue, algorithm reported as an expression score (Effective 10/01/2018)

0070U CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, common and select rare variants (Effective 10/01/2018)

0071U CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug

metabolism) gene analysis, full gene sequence (List separately in addition to code for primary procedure) (Effective 10/01/2018)

0072U

CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug

metabolism) gene analysis, targeted sequence analysis (ie, CYP2D6-2D7 hybrid gene) (List separately in addition to code for primary procedure) (Effective 10/01/2018)

0073U

CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D7-2D6 hybrid gene) (List separately in addition to code for primary procedure) (Effective 10/01/2018)

0074U


metabolism) gene analysis, targeted sequence analysis (ie, non-duplicated gene when duplication/multiplication is trans) (List separately in addition to code for primary procedure) (Effective 10/01/2018)

0075U


metabolism) gene analysis, targeted sequence analysis (ie, 5' gene duplication/multiplication) (List separately in addition to code for primary procedure) (Effective 10/01/2018)

0076U


metabolism) gene analysis, targeted sequence analysis (ie, 3' gene

duplication/multiplication) (List separately in addition to code for primary procedure) (Effective 10/01/2018)

0077U Immunoglobulin paraprotein (M-protein), qualitative, immunoprecipitation and mass spectrometry, blood or urine, including isotype (Effective 10/01/2018)

0078U

Pain management (opioid-use disorder) genotyping panel, 16 common variants (ie,

ABCB1, COMT, DAT1, DBH, DOR, DRD1, DRD2, DRD4, GABA, GAL, HTR2A, HTTLPR, MTHFR, MUOR, OPRK1, OPRM1), buccal swab or other germline tissue sample, algorithm reported as positive or negative risk of opioid-use disorder (Effective 10/01/2018)




81105

Human Platelet Antigen 1 genotyping (HPA-1), ITGB3 (integrin, beta 3 [platelet

glycoprotein IIIa], antigen CD61 [GPIIIa]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-1a/b (L33P)

81106 Human Platelet Antigen 2 genotyping (HPA-2), GP1BA (glycoprotein Ib [platelet],

alpha polypeptide [GPIba]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-2a/b (T145M)

81107

Human Platelet Antigen 3 genotyping (HPA-3), ITGA2B (integrin, alpha 2b [platelet

glycoprotein IIb of IIb/IIIa complex], antigen CD41 [GPIIb]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-3a/b (I843S)

81108

Human Platelet Antigen 4 genotyping (HPA-4), ITGB3 (integrin, beta 3 [platelet glycoprotein IIIa], antigen CD61 [GPIIIa]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-4a/b (R143Q)

81109

Human Platelet Antigen 5 genotyping (HPA-5), ITGA2 (integrin, alpha 2 [CD49B,

alpha 2 subunit of VLA-2 receptor] [GPIa]) (eg, neonatal alloimmune

thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant (eg, HPA-5a/b (K505E))

81110

Human Platelet Antigen 6 genotyping (HPA-6w), ITGB3 (integrin, beta 3 [platelet

glycoprotein IIIa, antigen CD61] [GPIIIa]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-6a/b (R489Q)

81111

Human Platelet Antigen 9 genotyping (HPA-9w), ITGA2B (integrin, alpha 2b [platelet

glycoprotein IIb of IIb/IIIa complex, antigen CD41] [GPIIb]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-9a/b (V837M)

81112 Human Platelet Antigen 15 genotyping (HPA-15), CD109 (CD109 molecule) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-15a/b (S682Y)

81120 IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (e.g., glioma), common variants

(e.g., R132H, R132C) (Effective 01/01/2018)

81121 IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (e.g., glioma), common variants (e.g., R140W, R172M) (Effective 01/01/2018)

81161 DMD (dystrophin) (e.g., Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed

81162 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements)

81163 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg,

hereditary breast and ovarian cancer) gene analysis; full sequence analysis (Effective 01/01/2019)

81164 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg,

hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) (Effective 01/01/2019)

81165 BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis (Effective 01/01/2019)

81166 BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer)

gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) (Effective 01/01/2019)

81167 BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) (Effective 01/01/2019)

81170 ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (e.g., acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain




81171 AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles

81172

AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2

[FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methylation status) (Effective 01/01/2019)

81173 AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence (Effective 01/01/2019)

81174 AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X

chromosome inactivation) gene analysis; known familial variant (Effective 01/01/2019)

81175 ASXL1 (additional sex combs like 1, transcriptional regulator) (e.g., myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; full gene sequence (Effective 01/01/2018)

81176

ASXL1 (additional sex combs like 1, transcriptional regulator) (e.g., myelodysplastic

syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; targeted sequence analysis (e.g., exon 12) (Effective 01/01/2018)

81177 ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles (Effective 01/01/2019)

81178 ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles (Effective 01/01/2019)


81180

ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease) gene

analysis, evaluation to detect abnormal (eg, expanded) alleles (Effective 01/01/2019)


81182 ATXN8OS (ATXN8 opposite strand [non-protein coding]) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles (Effective 01/01/2019)


81184 CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (eg, expanded) alleles (Effective 01/01/2019)

81185 CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full gene sequence (Effective 01/01/2019)

81186 CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; known familial variant (Effective 01/01/2019)

81187 CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg, myotonic dystrophy

type 2) gene analysis, evaluation to detect abnormal (eg, expanded) alleles (Effective 01/01/2019)

81188 CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles (Effective 01/01/2019)

81189 CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full gene sequence (Effective 01/01/2019)

81190 CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(s) (Effective 01/01/2019)

81200 ASPA (aspartoacylase) (e.g., Canavan disease) gene analysis, common variants (e.g., E285A, Y231X)

81201 APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence

81202 APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants




81203 APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion variants

81204

AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X

chromosome inactivation) gene analysis; characterization of alleles (eg, expanded size or methylation status) (Effective 01/01/2019)

81205 BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (e.g., Maple syrup urine disease) gene analysis, common variants (e.g., R183P, G278S, E422X)

81206 BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative

81207 BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative

81208 BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; other breakpoint, qualitative or quantitative

81209 BLM (Bloom syndrome, RecQ helicase-like) (e.g., Bloom syndrome) gene analysis, 2281del6ins7 variant

81210 BRAF (B-Raf proto-oncogene, serine/threonine kinase) (e.g., colon cancer, melanoma), gene analysis, V600 variant(s)

81211

BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1 (i.e., exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb) (Expired 12/31/2018 – See 81162-81164)

81212 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated)

(e.g., hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants

81213 BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer)

gene analysis; uncommon duplication/deletion variants (Expired 12/31/2018 – See 81162-81164)

81214

BRCA1 (breast cancer 1) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants (i.e., exon 13 del

3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb) (Expired 12/31/2018 – See 81165-81166)

81215 BRCA1 (BRCA1, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial variant

81216 BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis

81217 BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial variant

81218 CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (e.g., acute myeloid leukemia), gene analysis, full gene sequence

81219 CALR (calreticulin) (e.g., myeloproliferative disorders), gene analysis, common variants in exon 9

81220 CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; common variants (e.g., ACMG/ACOG guidelines)

81221 CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; known familial variants

81222 CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; duplication/deletion variants

81223 CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; full gene sequence

81224 CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; intron 8 poly-T analysis (e.g., male infertility)

81225 CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *8, *17)




81226

CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug

metabolism), gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN)

81227 CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *5, *6)

81228 Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., Bacterial Artificial Chromosome [BAC] or oligo-based comparative genomic hybridization [CGH] microarray analysis)

81229 Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of

genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities

81230 CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (e.g., drug metabolism), gene analysis, common variant(s) (e.g., *2, *22) (Effective 01/01/2018)

81231 CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (e.g., drug metabolism),

gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *7) (Effective 01/01/2018)

81232 DPYD (dihydropyrimidine dehydrogenase) (e.g., 5-fluorouracil/5-FU and capecitabine

drug metabolism), gene analysis, common variant(s) (e.g., *2A, *4, *5, *6) (Effective 01/01/2018)

81233 BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) (Effective 01/01/2019)

81234 DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles (Effective 01/01/2019)

81235

EGFR (epidermal growth factor receptor) (e.g., non-small cell lung cancer) gene

analysis, common variants (e.g., exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q)

81236 EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg,

myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence (Effective 01/01/2019)

81237

EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large

B-cell lymphoma) gene analysis, common variant(s) (eg, codon 646) (Effective 01/01/2019)

81238 F9 (coagulation factor IX) (e.g., hemophilia B), full gene sequence (Effective 01/01/2018)

81239 DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) (Effective 01/01/2019)

81240 F2 (prothrombin, coagulation factor II) (e.g., hereditary hypercoagulability) gene analysis, 20210G>A variant

81241 F5 (coagulation Factor V) (e.g., hereditary hypercoagulability) gene analysis, Leiden variant

81242 FANCC (Fanconi anemia, complementation group C) (e.g., Fanconi anemia, type C) gene analysis, common variant (e.g., IVS4+4A>T)

81243 FMR1 (Fragile X mental retardation 1) (e.g., fragile X mental retardation) gene analysis; evaluation to detect abnormal (e.g., expanded) alleles

81244 FMR1 (Fragile X mental retardation 1) (e.g., fragile X mental retardation) gene

analysis; characterization of alleles (e.g., expanded size and promoter methylation status)

81245 FLT3 (FMS-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis, internal tandem duplication (ITD) variants (i.e., exons 14, 15)

81247 G6PD (glucose-6-phosphate dehydrogenase) (e.g., hemolytic anemia, jaundice), gene analysis; common variant(s) (e.g., A, A-) (Effective 01/01/2018)

81248 G6PD (glucose-6-phosphate dehydrogenase) (e.g., hemolytic anemia, jaundice), gene analysis; known familial variant(s) (Effective 01/01/2018)

81249 G6PD (glucose-6-phosphate dehydrogenase) (e.g., hemolytic anemia, jaundice), gene analysis; full gene sequence (Effective 01/01/2018)




81250 G6PC (glucose-6-phosphatase, catalytic subunit) (e.g., Glycogen storage disease, Type 1a, von Gierke disease) gene analysis, common variants (e.g., R83C, Q347X)

81251 GBA (glucosidase, beta, acid) (e.g., Gaucher disease) gene analysis, common

variants (e.g., N370S, 84GG, L444P, IVS2+1G>A)

81252 GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (e.g., nonsyndromic hearing loss) gene analysis; full gene sequence

81253 GJB2 (gap junction protein, beta 2, 26kDa; connexin 26) (e.g., nonsyndromic hearing loss) gene analysis; known familial variants

81254 GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) (e.g., nonsyndromic hearing

loss) gene analysis, common variants (e.g., 309kb [del(GJB6-D13S1830)] and 232kb [del(GJB6-D13S1854)])

81255 HEXA (hexosaminidase A [alpha polypeptide]) (e.g., Tay-Sachs disease) gene analysis, common variants (e.g., 1278insTATC, 1421+1G>C, G269S)

81256 HFE (hemochromatosis) (e.g., hereditary hemochromatosis) gene analysis, common variants (e.g., C282Y, H63D)

81257

HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart

hydrops fetalis syndrome, HbH disease), gene analysis; common deletions or variant (e.g., Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, Constant Spring)

81258 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial variant (Effective 01/01/2018)

81259 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart

hydrops fetalis syndrome, HbH disease), gene analysis; full gene sequence (Effective 01/01/2018)

81260 IKBKAP (inhibitor of kappa light polypeptide gene enhancer in B-cells, kinase

complex-associated protein) (e.g., familial dysautonomia) gene analysis, common variants (e.g., 2507+6T>C, R696P)

81261 IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); amplified methodology (e.g., polymerase chain reaction)

81262 IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemias and lymphomas, B-cell),

gene rearrangement analysis to detect abnormal clonal population(s); direct probe methodology (e.g., Southern blot)

81263 IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemia and lymphoma, B-cell), variable region somatic mutation analysis

81264 IGK@ (Immunoglobulin kappa light chain locus) (e.g., leukemia and lymphoma, B-

cell), gene rearrangement analysis, evaluation to detect abnormal clonal population(s)

81265

Comparative analysis using Short Tandem Repeat (STR) markers; patient and comparative specimen (e.g., pre-transplant recipient and donor germline testing,

post-transplant non-hematopoietic recipient germline [e.g., buccal swab or other germline tissue sample] and donor testing, twin zygosity testing, or maternal cell contamination of fetal cells)

81266

Comparative analysis using Short Tandem Repeat (STR) markers; each additional specimen (e.g., additional cord blood donor, additional fetal samples from different

cultures, or additional zygosity in multiple birth pregnancies) (List separately in addition to code for primary procedure)

81267 Chimerism (engraftment) analysis, post transplantation specimen (e.g., hematopoietic stem cell), includes comparison to previously performed baseline analyses; without cell selection

81268 Chimerism (engraftment) analysis, post transplantation specimen (e.g.,

hematopoietic stem cell), includes comparison to previously performed baseline analyses; with cell selection (e.g., CD3, CD33), each cell type




81269

HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart

hydrops fetalis syndrome, HbH disease), gene analysis; duplication/deletion variants (Effective 01/01/2018)

81270 JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant

81271 HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles (Effective 01/01/2019)

81272 KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g.,

gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequence analysis (e.g., exons 8, 11, 13, 17, 18)

81273 KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g., mastocytosis), gene analysis, D816 variant(s)

81275 KRAS (Kirsten rat sarcoma viral oncogene homolog) (e.g., carcinoma) gene analysis; variants in exon 2 (e.g., codons 12 and 13)

81276 KRAS (Kirsten rat sarcoma viral oncogene homolog) (e.g., carcinoma) gene analysis; additional variant(s) (e.g., codon 61, codon 146)

81283 IFNL3 (interferon, lambda 3) (e.g., drug response), gene analysis, rs12979860 variant (Effective 01/01/2018)

81287 MGMT (O-6-methylguanine-DNA methyltransferase) (e.g., glioblastoma multiforme), methylation analysis

81288 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary non-

polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter methylation analysis

81290 MCOLN1 (mucolipin 1) (e.g., Mucolipidosis, type IV) gene analysis, common variants (e.g., IVS3-2A>G, del6.4kb)

81291 MTHFR (5,10-methylenetetrahydrofolate reductase) (e.g., hereditary hypercoagulability) gene analysis, common variants (e.g., 677T, 1298C)

81292 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis

81293 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants

81294

MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary non-

polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants

81295 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis

81296 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants

81297 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary non-


81298 MSH6 (mutS homolog 6 [E. coli]) (e.g. hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis

81299 MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants

81300 MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants

81301 Microsatellite instability analysis (e.g., hereditary non-polyposis colorectal cancer,

Lynch syndrome) of markers for mismatch repair deficiency (e.g., BAT25, BAT26), includes comparison of neoplastic and normal tissue, if performed

81302 MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis

81303 MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant




81304 MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants

81305

MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's

macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant (Effective 01/01/2019)

81310 NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, exon 12 variants

81311 NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (e.g., colorectal

carcinoma), gene analysis, variants in exon 2 (e.g., codons 12 and 13) and exon 3 (e.g., codon 61)

81313 PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (e.g., prostate cancer)

81314 PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (e.g.,

gastrointestinal stromal tumor [GIST]), gene analysis, targeted sequence analysis (e.g., exons 12, 18)

81315

PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha)

(e.g., promyelocytic leukemia) translocation analysis; common breakpoints (e.g., intron 3 and intron 6), qualitative or quantitative

81316 PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha)

(e.g., promyelocytic leukemia) translocation analysis; single breakpoint (e.g., intron 3, intron 6 or exon 6), qualitative or quantitative

81317 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis

81318 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants

81319 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary non-


81320 PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) (Effective 01/01/2019)

81321 PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis

81322 PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant

81323 PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant

81324

PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary

neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis

81325 PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis

81326 PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant

81327 SEPT9 (Septin9) (e.g., colorectal cancer) promotor methylation analysis

81328 SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (e.g.,

adverse drug reaction), gene analysis, common variant(s) (e.g., *5) (Effective 01/01/2018)

81329 SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene

analysis; dosage/deletion analysis (eg, carrier testing), includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed (Effective 01/01/2019)

81330 SMPD1(sphingomyelin phosphodiesterase 1, acid lysosomal) (e.g., Niemann-Pick disease, Type A) gene analysis, common variants (e.g., R496L, L302P, fsP330)

81331 SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein

ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis




81332

SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase, antitrypsin,

member 1) (e.g., alpha-1-antitrypsin deficiency), gene analysis, common variants (e.g., *S and *Z)

81334 RUNX1 (runt related transcription factor 1) (e.g., acute myeloid leukemia, familial

platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analysis (e.g., exons 3-8) (Effective 01/01/2018)

81335 TPMT (thiopurine S-methyltransferase) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3) (Effective 01/01/2018)

81336 SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; full gene sequence (Effective 01/01/2019)

81337 SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familial sequence variant(s) (Effective 01/01/2019)

81340 TRB@ (T cell antigen receptor, beta) (e.g., leukemia and lymphoma), gene

rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (e.g., polymerase chain reaction)

81341

TRB@ (T cell antigen receptor, beta) (e.g., leukemia and lymphoma), gene

rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (e.g., Southern blot)

81342 TRG@ (T cell antigen receptor, gamma) (e.g., leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s)

81345 TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region) (Effective 01/01/2019)

81346 TYMS (thymidylate synthetase) (e.g., 5-fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (e.g., tandem repeat variant) (Effective 01/01/2018)

81350 UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (e.g., irinotecan metabolism), gene analysis, common variants (e.g., *28, *36, *37)

81355 VKORC1 (vitamin K epoxide reductase complex, subunit 1) (e.g., warfarin metabolism), gene analysis, common variants (e.g., -1639G>A, c.173+1000C>T)

81361

HBB (hemoglobin, subunit beta) (e.g., sickle cell anemia, beta thalassemia,

hemoglobinopathy); common variant(s) (e.g., HbS, HbC, HbE) (Effective 01/01/2018)

81362 HBB (hemoglobin, subunit beta) (e.g., sickle cell anemia, beta thalassemia, hemoglobinopathy); known familial variant(s) (Effective 01/01/2018)

81363 HBB (hemoglobin, subunit beta) (e.g., sickle cell anemia, beta thalassemia, hemoglobinopathy); duplication/deletion variant(s) (Effective 01/01/2018)

81364 HBB (hemoglobin, subunit beta) (e.g., sickle cell anemia, beta thalassemia, hemoglobinopathy); full gene sequence (Effective 01/01/2018)

81370 HLA Class I and II typing, low resolution (e.g., antigen equivalents); HLA-A, -B, -C, -DRB1/3/4/5, and -DQB1

81371 HLA Class I and II typing, low resolution (e.g., antigen equivalents); HLA-A, -B, and -DRB1/3/4/5 (e.g., verification typing)

81372 HLA Class I typing, low resolution (e.g., antigen equivalents); complete (i.e., HLA-A, -B, and -C)

81373 HLA Class I typing, low resolution (e.g., antigen equivalents); one locus (e.g., HLA-A, -B, or -C), each

81374 HLA Class I typing, low resolution (e.g., antigen equivalents); one antigen equivalent (e.g., B*27), each

81375 HLA Class II typing, low resolution (e.g., antigen equivalents); HLA-DRB1/3/4/5 and -DQB1

81376 HLA Class II typing, low resolution (e.g., antigen equivalents); one locus (e.g., HLA-DRB1/3/4/5, -DQB1, -DQA1, -DPB1, or -DPA1), each

81377 HLA Class II typing, low resolution (e.g., antigen equivalents); one antigen equivalent, each




81378 HLA Class I and II typing, high resolution (ie, alleles or allele groups), HLA-A, -B, -C, and -DRB1

81379 HLA Class I typing, high resolution (i.e., alleles or allele groups); complete (i.e., HLA-

A, -B, and -C)

81380 HLA Class I typing, high resolution (i.e., alleles or allele groups); one locus (e.g., HLA-A, -B, or -C), each

81381 HLA Class I typing, high resolution (i.e., alleles or allele groups); one allele or allele group (e.g., B*57:01P), each

81382 HLA Class II typing, high resolution (i.e., alleles or allele groups); one locus (e.g., HLA-DRB1, -DRB3, -DRB4, -DRB5, -DQB1, -DQA1, -DPB1, or -DPA1), each

81383 HLA Class II typing, high resolution (i.e., alleles or allele groups); one allele or allele group (e.g., HLA-DQB1*06:02P), each

81400 Molecular pathology procedure, Level 1 analysis (short description)









81410

Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler

Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK

81411 Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler

Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2, MYH11, and COL3A1

81412

Ashkenazi Jewish associated disorders (e.g., Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease), genomic sequence analysis panel, must include sequencing of at least 9 genes, including ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, and SMPD1

81413

Cardiac ion channelopathies (e.g., Brugada syndrome, long QT syndrome, short QT

syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A

81414

Cardiac ion channelopathies (e.g., Brugada syndrome, long QT syndrome, short QT

syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1

81415 Exome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis

81416

Exome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence

analysis, each comparator exome (e.g., parents, siblings) (List separately in addition to code for primary procedure)

81417 Exome (e.g., unexplained constitutional or heritable disorder or syndrome); re-

evaluation of previously obtained exome sequence (e.g., updated knowledge or unrelated condition/syndrome)

81420 Fetal chromosomal aneuploidy (e.g., trisomy 21, monosomy X) genomic sequence analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and 21

81422 Fetal chromosomal microdeletion(s) genomic sequence analysis (e.g., DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood




81425 Genome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis

81426

Genome (e.g., unexplained constitutional or heritable disorder or syndrome);

sequence analysis, each comparator genome (e.g., parents, siblings) (List separately in addition to code for primary procedure)

81427 Genome (e.g., unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained genome sequence (e.g., updated knowledge or unrelated condition/syndrome)

81430

Hearing loss (e.g., nonsyndromic hearing loss, Usher syndrome, Pendred syndrome);

genomic sequence analysis panel, must include sequencing of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1, MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C, USH1G, USH2A, and WFS1

81431 Hearing loss (e.g., nonsyndromic hearing loss, Usher syndrome, Pendred syndrome);

duplication/deletion analysis panel, must include copy number analyses for STRC and DFNB1 deletions in GJB2 and GJB6 genes

81432

Hereditary breast cancer-related disorders (e.g., hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel,

must include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53

81433 Hereditary breast cancer-related disorders (e.g., hereditary breast cancer, hereditary

ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11

81434

Hereditary retinal disorders (e.g., retinitis pigmentosa, Leber congenital amaurosis,

cone-rod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A

81435

Hereditary colon cancer disorders (e.g., Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis); genomic sequence

analysis panel, must include sequencing of at least 10 genes, including APC, BMPR1A, CDH1, MLH1, MSH2, MSH6, MUTYH, PTEN, SMAD4, and STK11

81436

Hereditary colon cancer disorders (e.g., Lynch syndrome, PTEN hamartoma

syndrome, Cowden syndrome, familial adenomatosis polyposis); duplication/deletion analysis panel, must include analysis of at least 5 genes, including MLH1, MSH2, EPCAM, SMAD4, and STK11

81437

Hereditary neuroendocrine tumor disorders (e.g., medullary thyroid carcinoma,

parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); genomic sequence analysis panel, must include sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL

81438

Hereditary neuroendocrine tumor disorders (e.g., medullary thyroid carcinoma,

parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); duplication/deletion analysis panel, must include analyses for SDHB, SDHC, SDHD, and VHL

81439

Hereditary cardiomyopathy (e.g., hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy), genomic

sequence analysis panel, must include sequencing of at least 5 cardiomyopathy-related genes (e.g., DSG2, MYBPC3, MYH7, PKP2, TTN)

81440

Nuclear encoded mitochondrial genes (e.g., neurologic or myopathic phenotypes), genomic sequence panel, must include analysis of at least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK, MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2, SUCLG1, TAZ, TK2, and TYMP

81442

Noonan spectrum disorders (e.g., Noonan syndrome, cardio-facio-cutaneous

syndrome, Costello syndrome, LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, must include sequencing of at least 12 genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1




81443

Genetic testing for severe inherited conditions (eg, cystic fibrosis, Ashkenazi Jewish-

associated disorders [eg, Bloom syndrome, Canavan disease, Fanconi anemia type C, mucolipidosis type VI, Gaucher disease, Tay-Sachs disease], beta

hemoglobinopathies, phenylketonuria, galactosemia), genomic sequence analysis

panel, must include sequencing of at least 15 genes (eg, ACADM, ARSA, ASPA, ATP7B, BCKDHA, BCKDHB, BLM, CFTR, DHCR7, FANCC, G6PC, GAA, GALT, GBA, GBE1, HBB, HEXA, IKBKAP, MCOLN1, PAH) (Effective 01/01/2019)

81445

Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (e.g., ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2,

JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed

81448

Hereditary peripheral neuropathies (e.g., Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral

neuropathy-related genes (e.g., BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1) (Effective 01/01/2018)

81450

Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, DNA and RNA analysis when performed, 5-50 genes (e.g., BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, MLL, NRAS, NPM1, NOTCH1), interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed

81455

Targeted genomic sequence analysis panel, solid organ or hematolymphoid

neoplasm, DNA and RNA analysis when performed, 51 or greater genes (e.g., ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN,

RET), interrogation for sequence variants and copy number variants or rearrangements, if performed

81460

Whole mitochondrial genome (e.g., Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy, ataxia, and retinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]), genomic sequence,

must include sequence analysis of entire mitochondrial genome with heteroplasmy detection

81465 Whole mitochondrial genome large deletion analysis panel (e.g., Kearns-Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if performed

81470

X-linked intellectual disability (XLID) (e.g., syndromic and non-syndromic XLID);

genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2

81471

X-linked intellectual disability (XLID) (e.g., syndromic and non-syndromic XLID);

duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2

81479 Unlisted molecular pathology procedure

81490 Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score

81500 Oncology (ovarian), biochemical assays of two proteins (CA-125 and HE4), utilizing serum, with menopausal status, algorithm reported as a risk score

81503 Oncology (ovarian), biochemical assays of five proteins (CA-125, apolipoprotein A1,

beta-2 microglobulin, transferrin, and pre-albumin), utilizing serum, algorithm reported as a risk score

81504 Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores




81506

Endocrinology (type 2 diabetes), biochemical assays of seven analytes (glucose,

HbA1c, insulin, hs-CRP, adiponectin, ferritin, interleukin 2-receptor alpha), utilizing serum or plasma, algorithm reporting a risk score

81518

Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes

(7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy (Effective 01/01/2019)

81519 Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21

genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score

81520

Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes

(50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence risk score (Effective 01/01/2018)

81521

Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes

and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis (Effective 01/01/2018)

81525 Oncology (colon), mRNA, gene expression profiling by real-time RT-PCR of 12 genes

(7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence score

81535

Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by

DAPI stain and morphology, predictive algorithm reported as a drug response score; first single drug or drug combination

81536

Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by

DAPI stain and morphology, predictive algorithm reported as a drug response score; each additional single drug or drug combination (List separately in addition to code for primary procedure)

81538 Oncology (lung), mass spectrometric 8-protein signature, including amyloid A,

utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival

81539

Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total

PSA, Free PSA, Intact PSA, and human kallikrein-2 [hK2]), utilizing plasma or serum, prognostic algorithm reported as a probability score

81540

Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time

RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype

81541

Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46

genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score (Effective 01/01/2018)

81545 Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (e.g., benign or suspicious)

81551

Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes

(GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm

reported as a likelihood of prostate cancer detection on repeat biopsy (Effective 01/01/2018)

81595 Cardiology (heart transplant), mRNA, gene expression profiling by real-time

quantitative PCR of 20 genes (11 content and 9 housekeeping), utilizing subfraction of peripheral blood, algorithm reported as a rejection risk score

81599 Unlisted multianalyte assay with algorithmic analysis

84999 Unlisted chemistry procedure

85999 Unlisted hematology and coagulation procedure

86152 Cell enumeration using immunologic selection and identification in fluid specimen (e.g., circulating tumor cells in blood)




86153

Cell enumeration using immunologic selection and identification in fluid specimen

(e.g., circulating tumor cells in blood); physician interpretation and report, when required

86294 Immunoassay for tumor antigen, qualitative or semiquantitative (e.g., bladder tumor antigen)

86316 Immunoassay for tumor antigen, other antigen, quantitative (e.g., CA 50, 72-4, 549), each

86386 Nuclear Matrix Protein 22 (NMP22), qualitative

86849 Unlisted immunology procedure

88120 Cytopathology, in situ hybridization (e.g., FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual

88121 Cytopathology, in situ hybridization (e.g., FISH), urinary tract specimen with

morphometric analysis, 3-5 molecular probes, each specimen; using computer-assisted technology

88199 Unlisted cytopathology procedure

88341

Immunohistochemistry or immunocytochemistry, per specimen; each additional

single antibody stain procedure (List separately in addition to code for primary procedure)

88342 Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure

88363 Examination and selection of retrieved archival (i.e., previously diagnosed) tissue(s) for molecular analysis (e.g., KRAS mutational analysis)

88365 In situ hybridization (e.g., FISH), each probe

88367 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative) each probe; using computer-assisted technology

88368 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative) each probe; manual

88399 Unlisted surgical pathology procedure

89240 Unlisted miscellaneous pathology test

89398 Unlisted reproductive medicine laboratory procedure

CPT® is a registered trademark of the American Medical Association

HCPCS Code Description

G0452 Molecular pathology procedure; physician interpretation and report

S0265 Genetic counseling, under physician supervision, each 15 minutes

S3800 Genetic testing for amyotrophic lateral sclerosis (ALS)

S3841 Genetic testing for retinoblastoma

S3842 Genetic testing for Von Hippel-Lindau disease

S3845 Genetic testing for alpha-thalassemia

S3846 Genetic testing for hemoglobin E beta-thalassemia

S3849 Genetic testing for Niemann-Pick disease

S3850 Genetic testing for sickle cell anemia

S3852 DNA analysis for APOE epsilon 4 allele for susceptibility to Alzheimer's disease

S3853 Genetic testing for myotonic muscular dystrophy

S3861 Genetic testing, sodium channel, voltage-gated, type V, alpha subunit (SCN5A) and variants for suspected Brugada Syndrome

S3870 Comparative genomic hybrization (CGH) microarray testing for developmental delay, autism spectrum disorder intellectual disability

Modifier Description

TC Technical component



ICD-10 Diagnosis Code

Molecular Pathology/Molecular Diagnostics/Genetic Testing: ICD-10 Diagnosis Code List

PURPOSE

The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services.

The document can be used as a guide to help determine applicable: Medicare coding or billing requirements, and/or Medical necessity coverage guidelines; including documentation requirements. UnitedHealthcare follows Medicare guidelines such as LCDs, NCDs, and other Medicare manuals for the purposes of determining coverage. It is expected providers retain or have access to appropriate documentation when requested to support coverage. Please utilize the links in the References section below to view the Medicare source materials used

to develop this resource document. This document is not a replacement for the Medicare source materials that outline Medicare coverage requirements. Where there is a conflict between this document and Medicare source materials, the Medicare source materials will apply. REFERENCES

CMS National Coverage Determinations (NCDs)

NCD 90.2 Next Generation Sequencing (NGS) NCD 190.3 Cytogenetic Studies

NCD 190.7 Human Tumor Stem Cell Drug Sensitivity Assays

CMS Local Coverage Determinations (LCDs)

LCD Contractor Medicare Part A Medicare Part B

Immunohistochemistry, Drug Metabolism Testing, GeneSight for Depression, HLA Testing, Topographic Genotyping for Pancreas

(L34554) In Vitro Chemosensitivity & Chemoresistance Assays

Palmetto GBA AL, GA, NC, SC, TN, VA, WV AL, GA, NC, SC, TN, VA, WV

(L34864) Loss-of-Heterozygosity

Based Topographic Genotyping with PathfinderTG®/PancraGEN™

Novitas Solutions, Inc.

AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX


(L35072) MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing


(L35332) MolDX: CYP2C19,

CYP2D6, CYP2C9, and VKORC1 Genetic Testing

CGS KY, OH KY, OH

(L35443) MolDX: GeneSight ® Assay for Refractory Depression

CGS KY, OH KY, OH

(L35633) MolDX: GeneSight® Assay for Refractory Depression


(L35698) CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing

First Coast FL, PR, VI FL, PR, VI

(L35922) Lab: Special

Histochemical Stains and Immunohistochemical Stains


(L35986) Special Histochemical

Stains and Immunohistochemical Stains

CGS KY, OH KY, OH

(L36033) MolDX: HLA-B*15:02 Genetic Testing



CGS KY, OH KY, OH


Noridian AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/attachments/medadv/molecular-pathology-diagnostics-genetic-testing-dx-codes.pdf

http://kl/CONTENT/GUIDELINES%20&%20CLINICAL%20POLICIES/Molecular/NCD%2090.2%20Next%20Generation%20Sequencing%20(NGS)

http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=198&ncdver=1&DocID=190.3&kq=true&bc=gAAAAAgAAAAAAA%3d%3d&

http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=253&ncdver=1&DocID=190.7&kq=true&bc=gAAAAAgAAAAAAA%3d%3d&

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34554&ver=20&Date=&DocID=L34554&bc=iAAAABABAAAA&


https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34864&ver=23&Date=&DocID=L34864&bc=iAAAABAAAAAA&


























https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36145&ver=4&DocID=L36145&bc=gAAAABAAAAAA&






(L36149) MolDX: HLA-B*15:02

Genetic Testing

Noridian AK, AZ, ID, MT, ND, OR, SD,

UT, WA, WY

AK, AZ, ID, MT, ND, OR, SD,

UT, WA, WY


Stains & Immunohistochemical Stains





(L36312) MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing

Noridian AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY

AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY









(L36353) Special Histochemical Stains and Immunohistochemical Stains





WPS AK, AL, AR, AZ, CO, CT, DE,

FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE,

NH, NJ, NM, NV, OH, OK, OR, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY

IA, IN, KS, MI, MO, NE

(L36464) MolDX: HLA-DQB1*06:02 Testing for Narcolepsy



CGS KY, OH KY, OH






L36634 (In Vitro Chemosensitivity & Chemoresistance Assays)











FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY





















































(L37260) MolDX: Prometheus IBD

sgi Diagnostic Policy


(L37266) MolDX: AlloSure® Donor-Derived Cell-Free DNA Test


(L37299) MolDX: Prometheus IBD sgi Diagnostic Policy








CGS KY, OH KY, OH





CGS KY, OH KY, OH










(L35660) Pathology and

Laboratory: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing RETIRED 02/25/2018

Cahaba AL, GA, TN AL, GA, TN

Cancer Genetic Testing

(L33420) Lab: Bladder/Urothelial Tumor Markers


(L33586) Gene Expression Profiling Panel for use in the Management of Breast Cancer Treatment


(L33965) Urinary Tumor Markers for Bladder Cancer





















https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37362&ver=4&DocID=L37362&bc=gAAAABABAAAA&



















(L34912) Genetic Testing for Lynch Syndrome


(L35024) MolDX: Genetic Testing for Lynch Syndrome


(L35062) Biomarkers Overview Novitas Solutions, Inc.



(L35073) MolDX: NRAS Genetic Testing



CGS KY, OH KY, OH

(L35396) Biomarkers for Oncology Novitas Solutions, Inc.




CGS KY, OH KY, OH

(L35631) MolDX: Breast Cancer

Index℠ Genetic Assay


(L35632) MolDX: ConfirmMDx Epigenetic Molecular Assay


(L35868) MolDX: Decipher® Prostate Cancer Classifier Assay


(L35869) MolDX: Prolaris™ Prostate Cancer Genomic Assay


(L35974) MolDX: MGMT Promoter Methylation Analysis



CGS KY, OH KY, OH

(L36006) MolDX-CDD: ConfirmMDx Epigenetic Molecular Assay

CGS KY, OH KY, OH

(L36082) MolDX: BRCA1 and BRCA2 Genetic Testing



CGS KY, OH KY, OH

(L36125) MolDX: Breast Cancer Assay: Prosigna


(L36153) MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay












(L36206) MolDX: Genomic Health™

Oncotype DX® Prostate Cancer Assay

CGS KY, OH KY, OH




























https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36002&ver=10&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=MolDX&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&





































(L36314) MolDX: Breast Cancer Index℠ Genetic Assay


(L36316) MolDX: Breast Cancer Index?; Genetic Assay










(L36350) MolDX: Prolaris™ Prostate

Cancer Genomic Assay


UT, WA, WY


UT, WA, WY


WPS AK, AL, AR, AZ, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE,





(L36368) MolDX: Genomic Health™

Oncotype DX® Prostate Cancer Assay








(L36376) Genomic Sequence

Analysis Panels in the Treatment of Non-Small Cell Lung Cancer

NGS CT, IL, MA, ME, MN, NH, NY, RI, VT, WI

CT, IL, MA, ME, MN, NH, NY, RI, VT, WI







CGS KY, OH KY, OH


CGS KY, OH KY, OH


CGS KY, OH KY, OH

(L36499) BRCA1 and BRCA2 Genetic Testing



CGS KY, OH KY, OH

(L36665) MolDX: ProMark Risk Score


(L36675) MolDX- CDD: ProMark Risk Score

CGS KY, OH KY, OH
































https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36380&ver=10&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=prosigna&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36380&ver=10&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=prosigna&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&




























(L36706) MolDX: ProMark Score Noridian AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY


(L36715) BRCA1 and BRCA2 Genetic Testing




(L36763) MolDX: 4Kscore Assay Palmetto GBA AL, GA, NC, SC, TN, VA, WV AL, GA, NC, SC, TN, VA, WV







WPS AK, AL, AR, AZ, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI,

MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY




FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK,

OR, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY












WPS AK, AL, AR, AZ, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE,







https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36704&ver=11&DocType=Active&bc=AgIAAAAAAAAA&
























WPS AK, AL, AR, AZ, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN,

KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY


(L36827) MolDX: APC and MUTYH Gene Testing


(L36854) MolDX: Percepta© Bronchial Genomic Classifier







(L36886) MolDX: Percepta©

Bronchial Genomic Classifier Noridian AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV


Bronchial Genomic Classifier Noridian AK, AZ, ID, MT, ND, OR, SD,

UT, WA, WY AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY


Bronchial Genomic Classifier CGS KY, OH KY, OH


CGS KY, OH KY, OH

(L36912) MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)


(L36941) MolDX: Oncotype DX®

Breast Cancer for DCIS (Genomic Health™)



Breast Cancer for DCIS (Genomic Health™)



(L36951) MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)

CGS KY, OH KY, OH

(L36975) Bladder/Urothelial Tumor Markers

CGS KY, OH KY, OH

(L36979) MolDX: 4Kscore Assay CGS KY, OH KY, OH























































(L37013) MolDX: 4Kscore Assay WPS AK, AL, AR, AZ, CO, CT, DE,



(L37033) MolDX: DecisionDx-UM (Uveal Melanoma)







(L37043) MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease



Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease



Cancer Genomic Assay for Men with

Favorable Intermediate Risk Disease




Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease

CGS KY, OH KY, OH

(L37226) MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease




(L37130) MolDX: DecisionDx-UM

(Uveal Melanoma)

CGS KY, OH KY, OH

(L37195) MolDX: Percepta© Bronchial Genomic Classifier





https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37011&ver=11&DocType=Active&bc=AgIAAAABAAAA&

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37011&ver=11&DocType=Active&bc=AgIAAAABAAAA&




































(L37199) MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic

Health™)




(L37210) MolDX: Decision Dx-UM (Uveal Melanoma)






FL, GA, HI, IA, ID, IL, IN,




Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer


(L37264) MolDX: EndoPredict Breast Cancer Gene Expression Test


(L37295) MolDX: EndoPredict® Breast Cancer Gene Expression Test





(L37311) MolDX: EndoPredict® Breast Cancer Gene Expression Test









CGS KY, OH KY, OH






(L37356) MolDX: EndoPredict Breast Cancer Gene Expression Test

CGS KY, OH KY, OH

(L37366) MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC)

CGS KY, OH KY, OH


































https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37356&ver=4&CntrctrSelected=239*1&Cntrctr=239&DocType=2&bc=AAACAAQBAAAA&

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37356&ver=4&CntrctrSelected=239*1&Cntrctr=239&DocType=2&bc=AAACAAQBAAAA&









(L37606) Genomic Sequence Analysis Panels in the Treatment of

Hematolymphoid Diseases



(L37649) MolDX: Guardant360®

Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC)















(L37701) MolDX: Oncotype DX AR-

V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC)


(L37725) MolDX: DecisionDx-Melanoma


(L37733) Biomarker Testing (Prior

to Initial Biopsy) for Prostate Cancer Diagnosis



(L37744) MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with

Metastatic Castrate Resistant Prostate Cancer (MCRPC)



(L37746) MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC)


(L37785) MolDX: Decipher® Biopsy

Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease "Future Effective 04/01/2019"


(L37792) 4Kscore Test Algorithm "Future Effective 03/21/2019"




(L37794) MolDX: Breast Cancer Index™ (BCI) Gene Expression Test


(L37798) Noncovered Service -

4Kscore Test Algorithm "Future Effective 03/18/2019"


(L37810) Genomic Sequence Analysis Panels in the Treatment of

Solid Organ Neoplasms "Future Effective 04/01/2019"







































https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37785&ContrId=378&ver=3&ContrVer=1&CntrctrSelected=378*1&Cntrctr=378&LCntrctr=378*1%7c379*1%7c380*1%7c381*1&DocType=4&bc=AgACAAQAAAAA&





https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37792&ver=7&DocType=4&bc=AAIAAAAAAAAA&

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37792&ver=7&DocType=4&bc=AAIAAAAAAAAA&



https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37798&ver=5&DocType=4&bc=AgIAAAAAAAAA&











(L37832) MolDX: Breast Cancer Index™ (BCI) Gene Expression Test

"Future Effective 04/01/2019"

CGS KY, OH KY, OH

(L37836) MolDX: Oncotype DX AR-

V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) "Future Effective 03/25/2019"

CGS KY, OH KY, OH

(L37851) Biomarker Testing for

Neuroendocrine Tumors/Neoplasms "Future Effective 04/01/2019"



(L37870) MolDX: Inivata,

InVisionFirst, Liquid Biopsy for Patients with Lung Cancer "Future Effective 04/08/2019"



Laboratory: Genetic Testing for

Lynch Syndrome RETIRED 02/25/2018


(L36143) MolDX: NSCLC,

Comprehensive Genomic Profile Testing RETIRED 09/24/2018



Comprehensive Genomic Profile Testing RETIRED 09/24/2018

CGS KY, OH KY, OH

(L36194) MolDX: NSCLC, Comprehensive Genomic Profile Testing RETIRED 09/24/2018



Comprehensive Genomic Profile

Testing RETIRED 09/24/2018




Laboratory: Partial Genome Profiling in Non Small Cell Lung Cancer (NSCLC) RETIRED 02/25/2018


(L36483) MolDX: Chromosome

1p/19q Deletion Analysis RETIRED 02/27/2018


(L36487) MolDX: Chromosome 1p/19q deletion analysis RETIRED 01/01/2018

CGS KY, OH KY, OH




UT, WA, WY


UT, WA, WY





Laboratory: K-ras Testing prior to Treatment of Colorectal Cancer (CRC) RETIRED 02/25/2018


https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37832&ContrId=228&ver=4&ContrVer=2&CntrctrSelected=228*2&Cntrctr=228&name=&DocType=4&bc=AAACAAQAAAAA&



















(L36741) Pathology and Laboratory: BRCA1 and BRCA2

Genetic Testing RETIRED 02/25/2018


(L36803) MolDX: NSCLC, Comprehensive Genomic Profile Testing RETIRED 11/01/2018

WPS AK, AL, AR, AZ, CT, FL, GA, IA, ID, IL, IN, KS, KY, LA, MA, ME, MI, MN, MO, MS,

MT, NC, ND, NE, NH, NJ, OH, OR, RI, SC, SD, TN, UT, VA, VI, VT, WA, WI, WV, WY


(L36926) Genomic Sequence Analysis Panels in the Treatment of Acute Myelogenous Leukemia (AML) RETIRED 07/31/2018





WPS AK, AL, AR, AZ, CT, FL, GA,

IA, ID, IL, IN, KS, KY, LA,

MA, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, OH, OR, RI, SC, SD, TN, UT, VA, VI, VT, WA, WI, WV, WY


(L37078) Genomic Sequence

Analysis Panels in the Treatment of Myelodysplastic Syndromes (MDS) RETIRED 07/31/2018



Molecular Pathology

(L34518) Molecular Pathology Procedures for Human Leukocyte Antigen (HLA) Typing


(L34519) Molecular Pathology Procedures


(L35000) Molecular Pathology Procedures



(L35025) MolDX: Molecular Diagnostic Tests (MDT)




(L35984) MolDX: Genetic Testing

for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)

CGS KY, OH KY, OH

(L36011) MolDX: Molecular RBC Phenotyping

CGS KY, OH KY, OH

(L36021) Molecular Diagnostic

Tests (MDT)

CGS KY, OH KY, OH

(L36044) MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease




(L36089) MolDX: Genetic Testing for Hypercoagulability /

Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)

































Molecular Pathology

(L36117) MolDX: Genetic Testing for BCR-ABL Negative

Myeloproliferative Disease

CGS KY, OH KY, OH



Noridian AS, CA GU, HI, MP, NV AS, CA GU, HI, MP, NV











for BCR-ABL Negative Myeloproliferative Disease









(L36400) MolDX: Genetic Testing for Hypercoagulability/Thrombophilia

(Factor V Leiden, Factor II Prothrombin, and MTHFR)

















(L37031) MolDX: BDX-XL2 Palmetto GBA AL, GA, NC, SC, TN, VA, WV AL, GA, NC, SC, TN, VA, WV

(L37054) MolDX: Xpresys Lung Noridian AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV

(L37062) MolDX: Xpresys Lung Noridian AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY


(L37134) MolDX: BDX-XL2 CGS KY, OH KY, OH











































Molecular Pathology

(L37216) MolDX: BDX-XL2 WPS AK, AL, AR, AZ, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN,



(L37857) MolDX: Envisia, Veracyte,

Idiopathic Pulmonary Fibrosis Diagnostic Test "Future Effective 04/01/2019"


(L34762) Molecular Diagnostic Testing RETIRED 02/15/2017

WPS AK, AL, AR, AZ, CT, FL, GA, IA, ID, IL, IN, KS, KY, LA,

MA, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, OH, OR, RI, SC, SD, TN, UT, VA, VI, VT, WA, WI, WV, WY


(L34943) Pathology and Laboratory: Molecular Pathology

Procedures for Human Leukocyte Antigen (HLA) Typing RETIRED 02/25/2018


(L36444) Pathology and Laboratory: Molecular RBC Phenotype RETIRED 02/25/2018


Circulating Tumor Cell Assays

(L34066) MolDX: Circulating Tumor Cell Marker Assays








CGS KY, OH KY, OH

(L33279) Circulating Tumor Cell Testing RETIRED 05/25/2018



Laboratory: Circulating Tumor Cells (CTC) Assays RETIRED 02/25/2018


(L33951) Circulating Tumor Cell Marker Assays RETIRED 03/05/2017

CGS KY, OH KY, OH

(A54355) MolDX: Afirma™ Assay by

Veracyte Billing and Coding Guidelines RETIRED 01/05/2018



Veracyte Billing and Coding Guidelines RETIRED 01/05/2018



(A54444) MolDX: MammaPrint

Billing and Coding Guidelines RETIRED 01/01/2018


















Circulating Tumor Cell Assays

(A54446) MolDX: MammaPrint Billing and Coding Guidelines

RETIRED 01/01/2018



(A53799) Approved Gene Testing RETIRED 12/31/2017

CGS KY, OH KY, OH

(A54598) MolDX: FDA Approved

ALK Companion Diagnostic Tests Coding and Billing Guidelines RETIRED 02/27/2018

CGS KY, OH KY, OH

(A55248) MolDX: Approved Gene Testing RETIRED 10/01/2018

WPS AK, AL, AR, AZ, CT, FL, GA, IA, ID, IL, IN, KS, KY, LA, MA, ME, MI, MN, MO, MS,

MT, NC, ND, NE, NH, NJ, OH, OR, RI, SC, SD, TN, UT, VA, VI, VT, WA, WI, WV, WY


CMS Articles

Article Contractor Medicare Part A Medicare Part B

(A53095) MolDX: Bladder Tumor

Marker FISH Billing and Coding Guidelines Update

Palmetto AL, GA, NC, SC, TN, VA, WV AL, GA, NC, SC, TN, VA, WV

(A53099) MolDX: AlloMap Billing and Coding Guidelines Update


(A53100) MolDX: Avise PG Assay Billing/Coding Update


(A53101) MolDX: bioTheranostics Cancer TYPE ID® Update


(A53103) MolDX: HERmark® Assay by Monogram Update


(A53104) MolDX: MammaPrint

Billing and Coding Guidelines Update


(A53106) MolDX: Oncotype DX® Colon Cancer Assay Update


(A53110) MolDX: Vectra™ DA Coding and Billing Guidelines


(A53112) MolDX: OncoCee™ Billing and Coding Guidelines


(A53489) MolDX: PreDx® Coding and Billing Guidelines


(A53493) MolDX: HBB Gene Tests Billing and Coding Guidelines


(A53540) MolDX: BLM Gene

Analysis Coding and Billing Guidelines


(A53550) MolDX: ATP7B Gene Tests Coding and Billing Guidelines


(A53596) MolDX: IKBKAP Genetic Testing Billing and Coding Guidelines


(A53598) MolDX: HEXA Gene

Analysis Billing and Coding Guidelines

CGS KY, OH KY, OH

(A53600) MolDX: BCKDHB Gene Test Coding and Billing Guidelines


https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53095&ver=14&Date=&DocID=A53095&bc=hAAAABAAAAAA&




















https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53489&ver=8&Cntrctr=All&UpdatePeriod=767&bc=AQAAEAAAAAAA&

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53489&ver=8&Cntrctr=All&UpdatePeriod=767&bc=AQAAEAAAAAAA&






https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53550&ver=17&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=ATP7B&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53550&ver=17&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=ATP7B&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&












(A53602) MolDX: Aspartoacyclase 2

Deficiency (ASPA) Testing Coding and Billing Guidelines


(A53615) MolDX: CFTR Gene



(A53628) MolDX: FANCC Genetic Testing Billing and Coding Guidelines


(A53630) MolDX: MCOLN1 Genetic

Testing Coding and Billing Guidelines


(A54832) Short Tandem Repeat

(STR) Markers and Chimerism (codes 81265-81268) Coding and Billing Guidelines


(A54021) MolDX: FDA-Approved EGFR Tests


(A54191) MolDX: FDA-Approved BRAF Tests

CGS KY, OH KY, OH

(A54240) Bladder Tumor Marker FISH Billing and Coding Guidelines Update

CGS KY, OH KY, OH


CGS KY, OH KY, OH

(A54258) MolDX: CFTR Gene Analysis Billing and Coding Guidelines

CGS KY, OH KY, OH

(A54263) MolDX: FANCC Genetic

Testing Billing and Coding Guidelines

CGS KY, OH KY, OH


CGS KY, OH KY, OH



CGS KY, OH KY, OH

(A54270) MolDX: IKBKAP Genetic


CGS KY, OH KY, OH

(A54275) MolDX: LPA-Aspirin Genotype Coding and Billing Guidelines

CGS KY, OH KY, OH



CGS KY, OH KY, OH

(A54290) MolDX: myPap™ Billing and Coding Guidelines

CGS KY, OH KY, OH


CGS KY, OH KY, OH

(A54689) MolDX: Myriad’s BRACAnalysis CDx™ Coding and Billing Guidelines

CGS KY, OH KY, OH

(A54338) MolDX: Myriad’s

BRACAnalysis CDx™ Coding and Billing Guidelines














https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54832&ver=4&Date=&DocID=A54832&SearchType=Advanced&bc=JAAAABAAAAAA&








https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54240&ver=8&Date=&DocID=A54240&bc=hAAAABAAgAAA&




































Veracyte Billing and Coding Guidelines



Veracyte Billing and Coding Guidelines



(A54363) MolDX: AlloMap Billing and Coding Guidelines







(A54483) MolDX: Oncotype DX®

Colon Cancer Coding and Billing Guidelines


(A54472) MolDX: FDA-Approved KRAS Tests


(A55099) MolDX: BCKDHB Gene Test Billing and Coding Guidelines


(A55100) MolDX: BCKDHB Gene Test Billing and Coding Guidelines



(A55088) MolDX: Aspartoacyclase 2

Deficiency (ASPA) Testing Billing and Coding Guidelines


(A55089) MolDX: Aspartoacyclase 2 Deficiency (ASPA) Testing Billing and Coding Guidelines










(A55113) MolDX: BLM Gene Analysis Billing and Coding Guidelines


(A55114) MolDX: BLM Gene




(A55142) MolDX: Aspartoacyclase 2 Deficiency (ASPA) Testing Coding and Billing Guidelines


KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR,

RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY





















https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54472&ver=19&DocType=Active%7cFuture&bc=AgCAAAAAAAAA&

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54472&ver=19&DocType=Active%7cFuture&bc=AgCAAAAAAAAA&































(A55145) MolDX: BCKDHB Gene Test Coding and Billing Guidelines


FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI,

MO, MS, MT, NC, ND, NE,



(A55148) MolDX: BLM Gene Analysis Coding and Billing Guidelines


















NH, NJ, NM, NV, OH, OK, OR,



(A55168) MolDX: HEXA Gene Analysis Billing and Coding Guidelines






KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR,



(A55173) MolDX: LPA-Aspirin

Genotype Coding and Billing Guidelines
































FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI,

MO, MS, MT, NC, ND, NE,



(A55183) MolDX: FANCC Genetic Testing Billing and Coding Guidelines






(A55241) MolDX: Fragile X Billing and Coding Guidelines


(A55242) MolDX: Fragile X Billing and Coding Guidelines





IA, ID, IL, IN, KS, KY, LA, MA, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, OH, OR, RI, SC, SD, TN, UT, VA, VI, VT, WA, WI, WV, WY














(A55256) MolDX: HEXA Gene Analysis Billing and Coding Guidelines



(A55279) MolDX: LPA-Aspirin

Genotype Billing and Coding Guidelines


(A55280) MolDX: LPA-Aspirin Genotype Billing and Coding Guidelines















(A55594) MolDX: PreDx® Billing and Coding Guidelines





























https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=55279&ver=3&DocID=A55279&bc=gAAAABAAAAAA&





















(A55599) MolDX: PreDx® Billing and Coding Guidelines



(A55612) MolDX: IKBKAP Genetic






(A55822) MolDX: ThermoFisher

Oncomine Dx Target Test For Non-Small Cell Lung Cancer, Coding and Billing Guidelines









CGS KY, OH KY, OH

(A55881) MolDX: ThermoFisher Oncomine Dx Target Test For Non-

Small Cell Lung Cancer Billing and Coding Guidelines


(A55888) MolDX: ThermoFisher Oncomine Dx Target Test For Non-Small Cell Lung Cancer Billing and Coding Guidelines



(A56071)In Vitro Chemosensitivity

Assays-Billing and Coding Guidelines


(A56072) MolDX: Microsatellite

Instability-High (MSI-H) and Mismatch Repair Deficient (dMMR) Biomarker Coding and Billing Guidelines for Patients with Unresectable or Metastatic Solid Tumors


(A56073) In Vitro Chemosensitivity

Assays-Billing and Coding Guidelines



(A56103) MolDX: Microsatellite Instability-High (MSI-H) and

Mismatch Repair Deficient (dMMR) Biomarker Billing and Coding Guidelines for Patients with Unresectable or Metastatic Solid Tumors



Instability-High (MSI-H) and Mismatch Repair Deficient (dMMR) Biomarker Billing and Coding Guidelines for Patients with Unresectable or Metastatic Solid Tumors






























































Instability-High (MSI-H) and Mismatch Repair Deficient (dMMR)

Biomarker Coding and Billing

Guidelines for Patients with Unresectable or Metastatic Solid Tumors

CGS KY, OH KY, OH

(A56199) Molecular Pathology Procedures- Related to Molecular Policy Procedures LCD (L35000)



(A56270) MolDX: Clonoseq® Assay

for Assessment of Minimal Residual Disease (MRD) in Patients with Specific Lymphoid Malignancies


(A53638) MolDX: Fragile X Coding and Billing Guidelines Update


(A56307) MolDX: Clonoseq® Assay

for Assessment of Minimal Residual Disease (MRD) in Patients with Specific Lymphoid Malignancies

CGS KY, OH KY, OH

CMS Benefit Policy Manual Chapter 15; § 80.1–80.1.3 Clinical Laboratory Services

CMS Claims Processing Manual

Chapter 12; § 60 Payment for Pathology Services Chapter 16, § 10.2 General Explanation of Payment; § 20 Calculation of Payment Rates - Clinical Laboratory Test Fee Schedules; § 40 Billing for Clinical Laboratory Tests

CMS Transmittals

Transmittal 214, Change Request 10878, Dated 03/06/2019; National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)

UnitedHealthcare Commercial Policies

Carrier Testing for Genetic Diseases

Chemosensitivity and Chemoresistance Assays in Cancer Chromosome Microarray Testing (Non-Oncology Conditions) Gene Expression Tests

Genetic Testing for Hereditary Cancer Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions Pharmacogenetic Testing

Others

CMS Clinical Laboratory Fee Schedule, CMS Website MolDx Approved Tests, Palmetto Website PancraGEN™: Pancreatic Cancer Risk Classifier, Interpace Diagnostics Website GUIDELINE HISTORY/REVISION INFORMATION

Revisions to this summary document do not in any way modify the requirement that services be provided and

documented in accordance with the Medicare guidelines in effect on the date of service in question.

Date Action/Description

05/01/2019

Reformatted list of: o Applicable ICD-10 diagnosis codes o CMS Local Coverage Determinations (LCDs) o CMS Articles

04/01/2019 Reorganized policy template; relocated Terms and Conditions and Purpose

section

03/13/2019 Annual review





















https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c16.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c16.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R214NCD.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R214NCD.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/carrier-testing-for-genetic-diseases.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/chemosensitivity-chemoresistance-assays-cancer.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/chromosome-microarray-testing.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/gene-expression-tests.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/genetic-testing-hereditary-breast-ovarian-cancer-syndrome.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/molecular-oncology-testing-for-cancer.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/pharmacogenetic-testing.pdf

https://www.cms.gov/Medicare/Medicare-fee-for-service-Payment/clinicallabfeesched/index.html

https://www.palmettogba.com/palmetto/MolDX.nsf/DocsCatHome/MolDx

http://www.interpacediagnostics.com/pancragen/billing/



TERMS AND CONDITIONS The Medicare Advantage Policy Guidelines are applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates.

These Policy Guidelines are provided for informational purposes, and do not constitute medical advice. Treating physicians and healthcare providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care. Benefit coverage for health services is determined by the member specific benefit plan document* and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services

are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes the Medicare Advantage Policy Guidelines. Medicare Advantage Policy Guidelines are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. UnitedHealthcare may modify these Policy Guidelines at any time by publishing a new version of the policy on this

website. Medicare source materials used to develop these guidelines include, but are not limited to, CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Medicare Benefit Policy Manual, Medicare

Claims Processing Manual, Medicare Program Integrity Manual, Medicare Managed Care Manual, etc. The information presented in the Medicare Advantage Policy Guidelines is believed to be accurate and current as of the date of publication, and is provided on an "AS IS" basis. Where there is a conflict between this document and Medicare source materials, the Medicare source materials will apply.

You are responsible for submission of accurate claims. Medicare Advantage Policy Guidelines are intended to ensure that coverage decisions are made accurately based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Medicare Advantage Policy Guidelines use Current Procedural Terminology (CPT®), Centers for Medicare and Medicaid Services (CMS), or other coding guidelines. References to CPT® or other sources are for definitional purposes only and do not imply any right to reimbursement or guarantee claims payment. Medicare Advantage Policy Guidelines are the property of UnitedHealthcare. Unauthorized copying, use and

distribution of this information are strictly prohibited. *For more information on a specific member's benefit coverage, please call the customer service number on the back of the member ID card or refer to the Administrative Guide.

C16.0 C16.1 C16.2 C16.3 C16.4 C16.5 C16.6 C16.8 C16.9 C17.0 C17.1 C17.2 C17.3 C17.8 C17.9 C18.0 C18.1 C18.2 C18.3 C18.4 C18.5 C18.6 C18.7 C18.8 C18.9 C19 C20 C21.0 C21.1 C21.2

C21.8 C22.0 C22.1 C22.2 C22.3 C22.4 C22.7 C22.8 C22.9 C24.0 C24.9 C25.0 C25.1 C25.2 C25.3 C25.4 C25.7 C25.8 C25.9 C33 C34.00 C34.01 C34.02 C34.10 C34.11 C34.12 C34.2 C34.30 C34.31 C34.32 C34.80 C34.81 C34.82 C34.90 C34.91 C34.92 C38.4 C43.0 C43.10 C43.111 C43.112 C43.121 C43.122 C43.20 C43.21 C43.22 C43.30 C43.31 C43.39 C43.4 C43.51 C43.51 C43.52 C43.52 C43.59 C43.59 C43.60 C43.61

C43.62 C43.70 C43.71 C43.72 C43.8 C43.9 C45.0 C45.0 C45.1 C45.1 C45.1 C45.9 C47.0 C47.9 C48.0 C48.1 C48.1 C48.1 C48.2 C48.2 C48.2 C48.8 C48.8 C48.8 C49.0 C49.9 C49.A0 C49.A0 C49.A1 C49.A1 C49.A2 C49.A2 C49.A3 C49.A3 C49.A4 C49.A4 C49.A5 C49.A5 C49.A9 C49.A9 C50.011 C50.012 C50.019 C50.021 C50.022 C50.029 C50.111 C50.112 C50.119 C50.121 C50.122 C50.129 C50.211 C50.212 C50.219 C50.221 C50.222 C50.229 C50.311 C50.312 C50.319 C50.321 C50.322 C50.329 C50.411 C50.412 C50.419 C50.421 C50.422 C50.429 C50.511 C50.512 C50.519 C50.521 C50.522 C50.529 C50.611 C50.612 C50.619 C50.621 C50.622 C50.629 C50.811 C50.812 C50.819 C50.821 C50.822

C50.829 C50.911 C50.912 C50.919 C50.921 C50.922 C50.929 C54.0 C54.1 C54.2 C54.3 C54.8 C54.9 C55 C56.1 C56.2 C56.9 C57.00 C57.01 C57.02 C57.10 C57.11 C57.12 C57.20 C57.21 C57.22 C57.3 C57.4 C61 C64.1 C64.2 C64.9 C65.1 C65.2 C65.9 C66.1 C66.2 C66.9 C67.0 C67.1 C67.2 C67.3 C67.4 C67.5 C67.6 C67.7 C67.8 C67.9 C68.0 C68.1 C68.8 C68.9 C71.0 C71.1 C71.2 C71.3 C71.4 C71.5 C71.6 C71.7 C71.8 C71.9 C72.0 C76.0 C77.0 C77.1 C77.2 C77.3 C77.4 C77.5 C77.8 C77.9 C78.00 C78.01 C78.02 C78.5 C78.6 C78.7 C79.01 C79.02 C79.2 C79.31 C79.49 C79.51 C79.52 C79.61 C79.62

C79.89 C7A.00 C7A.010 C7A.010 C7A.011 C7A.012 C7A.019 C7A.020 C7A.021 C7A.022 C7A.023 C7A.024 C7A.025 C7A.026 C7A.029 C7A.090 C7A.091 C7A.092 C7A.093 C7A.094 C7A.095 C7A.096 C7A.098 C7A.1 C7A.8 C7B.00 C7B.01 C7B.01 C7B.02 C7B.03 C7B.04 C7B.09 C7B.1 C7B.8 C80.0 C80.1 C82.57 C84.97 C84.A7 C84.Z7 C85.17 C85.27 C85.87 C85.97 C86.1 C88.8 C91.00 C91.01 C91.02 C91.10 C91.11 C91.12 C91.30 C91.40 C91.41 C91.42 C91.50 C91.60

C91.61 C91.62 C91.A0 C91.Z0 C92.00 C92.01 C92.02 C92.10 C92.11 C92.12 C92.20 C92.21 C92.22 C92.30 C92.32 C92.40 C92.41 C92.42 C92.50 C92.51 C92.52 C92.60 C92.61 C92.62 C92.90 C92.92 C92.A0 C92.A1 C92.A2 C92.Z0 C92.Z2 C93.00 C93.02 C93.10 C93.11 C93.12 C93.90 C93.92 C93.Z0 C93.Z2 C94.00 C94.02 C94.40 C94.41 C94.42 C94.6 C94.80 C94.82 C95.00 C95.02 C95.10 C95.12 C95.90 C95.91 C95.92 C96.20 C96.21 C96.22 C96.29 C96.9 C96.Z D01.5 D01.7 D01.9 D02.21 D02.22 D03.0 D03.10 D03.111 D03.112 D03.121 D03.122 D03.20 D03.21 D03.22 D03.30 D03.39 D03.4 D03.51 D03.52 D03.59 D03.60 D03.61 D03.62 D03.70 D03.71 D03.72

D03.8 D03.9 D05.00 D05.01 D05.02 D05.10 D05.11 D05.12 D05.80 D05.81 D05.82 D05.90 D05.91 D05.92 D09.0 D12.0 D12.1 D12.2 D12.3 D12.4 D12.5 D12.6 D12.7 D12.8 D29.1 D34 D3A.010 D3A.011 D3A.012 D3A.019 D3A.020 D3A.021 D3A.022 D3A.023 D3A.024 D3A.025 D3A.026 D3A.029 D3A.090 D3A.091 D3A.092 D3A.093 D3A.094 D3A.095 D3A.096 D3A.098 D3A.8 D40.0 D41.4 D44.0 D44.9 D45 D46.0 D46.1 D46.20 D46.21 D46.22 D46.4

D46.9 D46.A D46.B D46.C D46.Z D47.01 D47.02 D47.09 D47.1 D47.3 D47.4 D47.9 D47.Z9 D48.1 D48.2 D49.0 D49.1 D49.2 D49.3 D49.4 D49.511 D49.512 D49.59 D49.6 D49.7 D49.89 D49.9 D60.0 D60.1 D60.8 D60.9 D61.01 D61.09 D61.1 D61.2 D61.3 D61.818 D61.89 D61.9 D69.49 D69.59 D69.6 D69.8 D69.9 D70.8 D70.9 D72.810 D72.818 D72.819 D72.821 D72.828 D72.829 D72.89 D72.9 D75.81 D75.89 D75.9 D77 E01.0 E01.1 E01.2 E04.0 E04.1 E04.2 E04.8 E04.9 E34.0 J91.0 K50.00 K63.5 L85.3 M05.011 M05.012 M05.021 M05.022 M05.031 M05.032 M05.041 M05.042 M05.051 M05.052 M05.061 M05.062 M05.071 M05.072 M05.09 M05.111

M05.112 M05.121 M05.122 M05.131 M05.132 M05.141 M05.142 M05.151 M05.152 M05.161 M05.162 M05.171 M05.172 M05.19 M05.211 M05.212 M05.221 M05.222 M05.231 M05.232 M05.241 M05.242 M05.251 M05.252 M05.261 M05.262 M05.271 M05.272 M05.29 M05.311 M05.312 M05.321 M05.322 M05.331 M05.332 M05.341 M05.342 M05.351 M05.352 M05.361 M05.362 M05.371 M05.372 M05.39 M05.411 M05.412 M05.421 M05.422 M05.431 M05.432 M05.441 M05.442 M05.451 M05.452 M05.461 M05.462 M05.471 M05.472 M05.49 M05.511 M05.512 M05.521 M05.522 M05.531 M05.532 M05.541 M05.542 M05.551 M05.552 M05.561 M05.562 M05.571 M05.572 M05.59 M05.611 M05.612 M05.621 M05.622 M05.631 M05.632 M05.641 M05.642 M05.651 M05.652 M05.661 M05.662 M05.671

M05.672 M05.69 M05.711 M05.712 M05.721 M05.722 M05.731 M05.732 M05.741 M05.742 M05.751 M05.752 M05.761 M05.762 M05.771 M05.772 M05.79 M05.811 M05.812 M05.821 M05.822 M05.831 M05.832 M05.841 M05.842 M05.851 M05.852 M05.861 M05.862 M05.871 M05.872 M05.89 M06.011 M06.012 M06.021 M06.022 M06.031 M06.032 M06.041 M06.042 M06.051 M06.052 M06.061 M06.062 M06.071 M06.072 M06.08 M06.09 M06.1 M06.211 M06.212 M06.221 M06.222 M06.231 M06.232 M06.241 M06.242 M06.251

M06.252 M06.261 M06.262 M06.271 M06.272 M06.28 M06.29 M06.311 M06.312 M06.321 M06.322 M06.331 M06.332 M06.341 M06.342 M06.351 M06.352 M06.361 M06.362 M06.371 M06.372 M06.38 M06.39 M06.811 M06.812 M06.821 M06.822 M06.831 M06.832 M06.841 M06.842 M06.851 M06.852 M06.861 M06.862 M06.871 M06.872 M06.88 M06.89 N40.0 N40.1 N40.2 N40.3 N42.31 N42.32 N42.39 N42.83 R16.1 R16.2 R31.0 R31.1 R31.29 R31.9 T86.00 T86.01 T86.02 T86.03 T86.09 T86.10 T86.11 T86.12 T86.13 T86.19 T86.20 T86.21 T86.22 T86.23 T86.290 T86.298 T86.30 T86.31 T86.32 T86.33 T86.39 T86.40 T86.41 T86.42 T86.43 T86.49 T86.5 T86.810 T86.811 T86.812 T86.818 T86.819 T86.830 T86.831

T86.832 T86.838 T86.839 T86.850 T86.851 T86.852 T86.858 T86.859 T86.890 T86.891 T86.892 T86.898 T86.899 T86.90 T86.91 T86.92 T86.93 T86.99 Z15.04 Z15.09 Z17.0 Z48.21 Z48.22 Z48.23 Z48.24 Z48.280 Z48.288 Z48.290 Z48.298 Z80.0 Z85.00 Z85.038 Z85.048 Z85.42 Z85.43 Z85.51 Z85.53 Z85.54 Z85.59 Z85.820 Z85.841 Z86.010 Z94.0 Z94.1 Z94.2 Z94.3 Z94.4 Z94.5 Z94.6 Z94.7 Z94.81 Z94.82 Z94.83 Z94.84 Z94.89 Z94.9 Z95.3 Z95.4

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