Persius/hicric huggingface dataset:
Billing and Coding: MolDX: BluePrint Test

The MolDX team has completed a technical assessment on BluePrint, a molecular
subtyping assay. To date, there is insufficient evidence to support the
required clinical utility for the established Medicare benefit category.
Therefore, the BluePrint test is a statutorily excluded test.  
  
To receive a BluePrint service denial, please submit the following claim
information:

  * CPT code 81479- Unlisted molecular pathology procedure
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a statutorily excluded service, append with a GY modifier
  * Select the appropriate diagnosis for the patient
  * Enter "appropriate Z-code ID" adjacent to the CPT code in the comment/narrative field for the following claim field/types:
    * Loop 2300 NTE01 for Part A and Loop 2400 NTE 02/ SV101-7 for Part B
    * Form locator 80 for Part A and Box 19 for Part B on paper claim. (Note: Only one test/identifier per paper claim may be submitted.)
Billing and Coding: MolDX: ENG and ACVRL1 Gene Tests

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder
with variable clinical presentation. Most common manifestations are epistaxis,
recurrent gastrointestinal bleeding, iron deficiency anemia, and mucocutaneous
telangectasias. Arteriovenous malformations (AVMs), of various organs (lung,
liver, brain) are common.  
  
The two most prevalent forms of HHT, Type 1 and Type 2, are caused by
mutations in the endoglin (ENG) or the ACVRL1 gene respectively. Although
identification of these gene mutations can confirm the diagnosis of HHT, these
tests are not necessary in many cases. HHT is generally established using well
vetted consensus criteria (most often the International Curacao Criteria
(ICC)). The ICC uses the clinical characteristics of epistaxis, cutaneous or
mucosal telangectasias, visceral AVMs, and a first-degree relative with HHT to
judge likelihood of a given patient having HHT. A 'definite' diagnosis is
established when a patient has 3 or 4 of these criteria. Genetic testing for
ENG/ACVRL1 is not warranted. A patient with 0 to 1 criteria is 'unlikely' to
have HHT, and similarly would not be a candidate for genetic testing. Patients
with 2 or 3 Curacao criteria are defined as "suspected" of HHT and are
candidates for ENG/ACVRL1 testing.  
  
Since screening of patients without signs or symptoms of HHT, who have a
first-degree relative with HHT, is not a Medicare benefit, CGS Administrators
and the MolDX program contractor has determined ENG and/or ACVRL1 genetic
testing and panels of tests that include ENG/ACVRL1 are statutorily excluded
services.  
  
**EXCEPTIONS:** For patients with "suspected" HHT in which diagnosis
confirmation would demonstrate an improved outcome, approval will be made on a
case-by-case basis through the appeal process.  
  
For tests that include ENG and ACVRL1 registered and assigned a single MolDX
ID, submit CPT code 81479.  
  
To receive an ENG and/or ACVRL1 gene test denial, please submit the following
claim information:

  * Select appropriate CPT code for test 
    * 81405-ENG, Duplication/deletion
    * 81406-ENG, full gene sequence
    * 81479-ACVRL1
    * 81479-ACVRL1 and ENG
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services 
    * For a voluntary issued ABN, append with GX modifier 
    * To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier
  *  For CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.
  * Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the  
following Part B claim field/types:

    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim
  * Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types: 
    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form
Billing and Coding: MolDX: FANCC Genetic Testing

Effective for dates of service on and after February 6, 2013  
  
FANCC gene testing is performed in association with Fanconi anemia (FA), a
condition characterized by physical abnormalities, bone marrow failure, and
increased risk of malignancy. For infants and children, FANCC genetic testing
is used to confirm the clinical findings, such as blood counts and bone marrow
biopsy, to diagnose FA. Genetic testing for adults is used to screen potential
carriers of the mutation. Therefore, the MolDX team has determined that
testing for the FANCC is not a Medicare benefit and is a statutorily excluded
service. In addition to single gene testing, MolDX will also deny panels of
tests that include the FANCC gene.  
  
To receive a FANCC test denial, please submit the following claim information:

  * CPT code 81242- FANCC, common variant
  * CPT code 81412-Ashkenazi Jewish Associated Disorders
  * CPT code 81443-Genetic testing for severe inherited conditions
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.  

    * For a voluntary issued ABN, append with GX modifier
    * To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier
  * For CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information. 
  * Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the  
following Part B claim field/types:

    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim
  * Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types: 
    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form
Billing and Coding: MolDX: Fragile X

Effective for dates of service on and after 01/1/2013  
  
The MolDX Team has determined that Fragile X testing is not a Medicare covered
service. Screening in the absence of signs and symptoms of an illness or
injury is not defined as a Medicare benefit. Therefore, MolDX will deny
testing for Fragile X as a statutorily excluded service.  
  
To receive a Fragile X service denial, please submit the following claim
information:

  * Select the appropriate CPT code:  

    * 81243- FMR1
    * 81244- FMR1, methylation analysis
    * 81470 - X-linked intellectual disability genomic sequence analysis panel
    * 81471 - X-linked intellectual disability genomic sequence analysis panel duplication / deletion
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.  

    * For a voluntary issued ABN, append with GX modifier
    * To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier

For CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred)
or the NTE field to submit this required information.

  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:  

    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:
    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form

NOTE: When entering the DEX Z-Code on the SV101-7 documentation field for
Part B claims please do not add additional characters or information on the
line.
Billing and Coding: MolDX: Immunohistochemistry (IHC) Indications for Breast
Pathology

Based on recommendations from the College of American Pathologists, the
American Society of Clinical Oncologists (ASCO), and the National
Comprehensive Cancer Network (NCCN), hormone receptor assays, estrogen
receptor (ER), progesterone receptor (PR), and Her-2/neu are the only current
biomarkers that demonstrate standardized value in breast cancer pathology
evaluation. Although other biomarkers, such as Ki-67, PI3K, and gene
expression assays, have been studied, no proven standardized value has been
established. Therefore, CGS Administrators and the MolDX program contractor
will allow ER, PR, and Her2 testing by IHC for patients with primary invasive
breast cancers and recurrent or metastatic cancers.  
  
To report an IHC service for an ER, PR, Her2, submit the following claim
information:  
  

CPT Code | Specimen | UOS  
---|---|---  
88342 | First single/multiplex stain | 1  
88341 | Each additional | 2  
  |   |  
---|---|---  
  |   |  
  |   |  
  |   |  
  
To report morphometric analysis, **select one** of the following codes based
on the type of morphometric analysis:

CPT Code | Service Type | UOS  
---|---|---  
88360 | Manual | 3  
88361 | Computer-assisted | 3
Billing and Coding: MolDX: L1CAM Gene Sequencing Guidelines

Effective for dates of service on and after January 29, 2013  
  
L1 syndrome refers to multiple disorders including X-linked hydrocephalus with
aqueduct of Sylvius (HSAS) stenosis, MASA syndrome (Mental retardation,
Aphasia, Spastic paraplegia, Adducted thumbs), SPG1 (X-linked complicated
hereditary spastic paraplegia type 1), and X-linked complicated corpus
callosum agenesis. Because there are many potential underlying causes for
congenital hydrocephalus, including syndromic and nonsyndromic cases,
recurrence risk and implications for family members is based upon underlying
etiology. Genetic testing of the L1CAM gene is used to confirm a clinical
diagnosis and provide recurrence risk. Therefore, the MolDX Team has
determined L1CAM full gene sequencing is a statutorily excluded test.  
  
To receive a L1CAM gene sequencing service denial, please submit the following
claim information:

  * CPT code 81407-L1CAM
  * CPT code 81470- X-linked intellectual disability genomic sequence analysis panel
  * CPT code 81471- X-linked intellectual disability genomic sequence analysis panel duplication / deletion
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services
  * Enter DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types: 
    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim
  * Enter DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:
    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form
Billing and Coding: MolDX: LPA-Intron 25 Genotype

The MolDX Team has completed a review of the research on the LPA-Intron 25
genotype test, developed to predict increased Coronary Heart Disease risk. To
date, there is insufficient evidence to support the required clinical utility
for the established Medicare benefit category. Therefore, the LPA-Intron 25
genotype test is a statutorily excluded service.  
  
As reviewed, the developer described the indication to perform a LPA-Intron 25
genotype test as a risk assessment for developing a disease or condition. Risk
assessment for developing a disease or condition in the absence of signs and
symptoms of an illness or injury is also not defined as a Medicare benefit.
Therefore, the LPA-Intron 25 genotype test would continue to be a statutory
excluded test.  
  
To receive a LPA-Intron 25 service denial, please submit the following claim
information:

  * CPT code 81479 -Unlisted molecular pathology procedure
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a statutorily excluded service, append with a GY modifier
  * Enter DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types: 
    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim
  * Enter DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types
    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form
Billing and Coding: MolDX: MCOLN1 Genetic Testing Guidelines

Effective for dates of service on and after February 6, 2013  
  
Mutations found in mucolipin 1 (MCOLN1) are associated with Mucolipidosis,
type IV, a disease characterized by psychomotor event delay in children
evident before the first year of life. For infants and children, MCOLN1
genetic testing is used to confirm the clinical findings to diagnose
Mucolipidosis. Genetic testing for adults is used to screen the population for
potential carriers of the mutation. Therefore, the MolDX Team has determined
that MCOLN1 genetic testing is not a Medicare benefit and is a statutorily
excluded service. In addition to single gene testing, MolDX will also deny
panels of tests that include a MCOLN1 gene test as a statutorily excluded
service.  
  
To receive a MCOLN1 test denial, please submit the following claim
information:

  * CPT code 81290, 81412, or 81443
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services   

    * For a voluntary issued ABN, append with GX modifier
    * To indicate a statutorily excluded service, append with a GY modifier
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:  

    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:
    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form

    *
Billing and Coding: MolDX: MECP2 Genetic Testing

Effective for dates of service on and after February 19, 2013  
  
Mutations found in methyl CpG binding protein 2(MECP2) are associated with
Rett syndrome. In classic Rett syndrome, suspected cases are identified
through specific clinical criteria in female children ages 1-5. Genetic
testing is used to confirm the clinical findings. Since 99% of classic cases
result in a single random mutation, genetic testing is not useful to screen
carriers. Therefore, the MolDX Team has determined that MECP2 genetic testing
is not a Medicare benefit and is a statutorily excluded service. In addition
to single disease testing, MolDX will also deny panels of tests that include a
MECP2 gene test as a statutorily excluded service.  
To receive a MECP2 test denial, please submit the following claim information:

    * Appropriate CPT codes:  

      * 81302- MECP2, full gene sequence
      * 81303- MECP2, known familial variant
      * 81304- MECP2, duplication/deletion variants
      * 81470 - X-linked intellectual disability genomic sequence analysis panel
      * 81471 - X-linked intellectual disability genomic sequence analysis panel duplication / deletion
      * 81479-MECP2, panel
    * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services   

      * For a voluntary issued ABN, append with GX HCPCS modifier
      * To indicate a statutorily excluded service, append with a GY HCPCS modifier
    * Select the appropriate diagnosis for the patient
    * Enter DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types
      * Loop 2400 or SV101-7 for the 5010A1 837P
      * Box 19 for paper claim
    * Enter DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types: 
      * Line SV202-7 for 837I electronic claim
      * Block 80 for the UB04 claim form
Billing and Coding: MolDx: VEGFR2 Tests

Effective for dates of service on and after 05/03/2013.  
  
Vascular endothelial growth factor, subtype 2, (VEGFR2) receptor has been
found to be oncogenic. Current studies have targeted VEGFR2 as a potential
therapeutic option. However, at present there is insufficient evidence to
establish a clear association between VEGFR2 mutations and treatment response.
Therefore, the MolDX Team has determined VEGFR2 testing is a statutorily
excluded service. MolDX will also deny panels of tests that include the VEGFR2
receptor.  
  
To receive a VEGFR2 service denial, please submit the following claim
information:

  * CPT code 81479
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:
    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:
    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form
Billing and Coding: MolDX: TP53 Gene Test

Effective for dates of service on and after June 24, 2013  
  
TP53 gene testing may be performed during the diagnosis of Li-Fraumeni
syndrome (LFS), a cancer predisposition syndrome associated with the
development of specific tumors. Clinical symptoms and diagnosis usually occur
prior to Medicare eligibility and carrier testing is not a covered benefit.  
  
To receive a TP53 gene sequencing service denial, please submit the following
claim information:

  * Select the appropriate CPTcode
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded 
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier services.
  * Select the appropriate diagnosis for the patient
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types: 
    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper clai
  * Enter DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:  

    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form
Billing and Coding: MolDX: TERC Gene Tests

Effective for dates of service on and after June 25, 2013  
  
Since the associated conditions associated with telomerase RNA component
(TERC) gene testing is limited to reproductive risk assessment, the MolDX team
has determined TERC gene testing is a statutorily excluded service. MolDX will
also deny tests that include one or more of TERC analysis reported with CPT
code 81479 as a statutorily excluded service.  
  
To receive a TERC analysis service denial, please submit the following claim
information:

  * CPT 81479 - Unlisted molecular pathology procedure
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.
  * Select the appropriate diagnosis for the patient
  * Enter DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types: 
    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim
  * Enter DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types: 
    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form
Billing and Coding: MolDX: STAT3 Gene Testing

Effective for dates of service on and after June 26, 2013  
  
STAT3 gene testing may be performed during the diagnosis of Autosomal Dominant
Hyper IgE Syndrome (AD-HIES). Since management is not determined by the
presence or absence of a STAT3 mutation in patients with a probably clinical
diagnosis, CGS Administrators and the MolDX program contractor has determined
STAT3 analysis is a statutorily excluded test.  
  
To receive a STAT3 analysis service denial, please submit the following claim
information:

    * CPT code 81405 - STAT3, targeted sequence analysis



    * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.



      * For a voluntary issued ABN, append with GX modifier



      * To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier



    * Select the appropriate diagnosis for the patient



    * Enter the appropriate DEX Z-codeTM identifier adjacent to the CPT code in the comment/narrative field for the following claim field/types:



      * Loop 2300 NTE01/SV202-7 for Part A or Loop 2400 NTE02/ SV101-7 for Part B



    * Form locator 80 for Part A or Box 19 for Part B on paper claim
Billing and Coding: MolDX: SMPD1 Genetic Testing

Effective for dates of service on and after February 7, 2013.  
  
Mutations found in sphingomyelin phosphodiesterase 1, (SMPD1) acid lysomal,
are associated with Niemann-Pick Disease, characterized by acid
sphingomyelinase (ASM) deficiency. For infants and children, SMPD1 genetic
testing is used to confirm the clinical findings from blood tests to diagnose
ASM. Genetic testing for adults is used to screen the population for potential
carriers of the mutation. Therefore, the MolDX team has determined that SMPD1
genetic testing is not a Medicare benefit and is a statutorily excluded
service. In addition to single disease testing, MolDX will also deny panels of
tests that include a SMPD1 gene test as a statutorily excluded service.  
  
To receive a SMPD1 test denial, please submit the following claim information:

  * CPT code 81330- SMPD1, common variants
  * CPT code 81412 - Ashkenazi Jewish Associated Disorders
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a statutorily excluded service, append with a GY modifier. An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services
Billing and Coding: MolDX: Mitochondrial Nuclear Gene Tests Guidelines

Effective for dates of service on and after January 29, 2013.  
  
Mitochondrial disorders are a group of conditions caused by dysfunction in the
mitochondrial respiratory chain. Current genetic testing methods are unable to
detect mutations in all individuals with suspected mitochondrial disease, and
there is no proven effective treatment for persons with a known mitochondrial
disease. Therefore, the MolDX Team has determined mitochondrial nuclear gene
tests do not support the required clinical utility for the established
Medicare benefit category and are statutorily excluded tests.  
  
To receive a mitochondrial nuclear panel service denial, please submit the
following claim information:

    * CPT code 81479- Unlisted molecular pathology procedure

    * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services   

      * For a voluntary issued ABN, append with GX HCPCS modifier
      * To indicate a statutorily excluded service, append with a GY HCPCS modifier
    * Enter DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types
      * Loop 2400 or SV101-7 for the 5010A1 837P
      * Box 19 for paper claim
    * Enter DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:
      * Line SV202-7 for 837I electronic claim
      * Block 80 for the UB04 claim for