Persius/hicric huggingface dataset:
Billing and Coding: MolDX: HEXA Gene Analysis

Effective for dates of service on and after February 7, 2013.

The clinical diagnosis of Hexosaminidase A deficiency, a disorder also known
as Tay-Sachs disease characterized by progressive weakness, loss of motor
skills, and increased startle reflex in infants, relies on blood tests that
result in absent or near absent beta-hexosaminidase A (HEX A) enzymatic
activity. Molecular genetic testing identifies HEXA gene mutation carriers at
risk for conceiving offspring with the disease. Therefore, HEXA 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 the HEXA gene as a statutorily excluded service.

To receive a HEXA gene test service denial, please submit the following claim
information:

  * Select the appropriate CPT code based on type of testing 
    * CPT code 81255 - HEXA, common variants
    * CPT code 81406 - HEXA, full gene sequence
    * 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
  * 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
Billing and Coding: MolDX: HTTLPR Gene Testing

Effective for dates of service on and after June 26, 2013.  
  
Serotonin Transporter genotyping (HTTLPR) has been associated with response to
selective serotonin reuptake inhibitors. However since the literature is
conflicting and limited by small sample sizes, the MolDX Team has determined
there is insufficient evidence to support coverage. Therefore, HTTLPR testing
is a statutorily excluded service.  
  
To receive a HTTLPR analysis 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
  * 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 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-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: IKBKAP Genetic Testing

Effective for dates of service on and after February 7, 2013.

Mutations to the IKBKAP (inhibitor of kappa light polypeptide gene enhancer in
B-cells, kinase complex-associated proteins) are associated with familial
dysautonomia (FD), a condition that affects the development of sensory,
sympathetic, and parasympathetic neurons. Genetic testing may be performed at
birth to diagnose FD. For adults, IKBKAP genetic testing identifies parents
that may be at risk for conceiving a child with the disease. Therefore, the
MolDX Team has determined that testing for the IKBKAP 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 an IKBKAP gene test
as a statutorily excluded service.  
  
To receive an IKBKAP test denial, please submit the following claim
information:

  * 81260 - IKBKAP, common variants 
  * 81412 - Ashkenazi Jewish associated disorders
  * 81443 - Genetic testing for severe inherited condition
  * 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
  * 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
Billing and Coding: MolDX: KIF6 Genotype

The MolDX Team has completed a review on the KIF6 genotype test. To date,
there is insufficient evidence to support the required clinical utility for
the established Medicare benefit category. Therefore, the KIF6 genotype test
is a statutorily excluded test.  
  
To receive a KIF6 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
  * 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
Billing and Coding: MolDX: know error

The know error DNA Specimen Provenance Assay is a forensic assay to confirm
that a surgical specimen belongs to the patient evaluated for treatment.
Although MolDX agrees the healthcare community should define and follow strict
procedures regarding patient and patient specimen identification and handling,
tests performed to measure the quality of a process do not provide information
to diagnose or treat a patient illness or injury as defined in the Medicare
benefit category. Therefore, the know error DNA Specimen Provenance Assay is
a statutorily excluded test. Although an Advance Beneficiary Notice (ABN) is
not required for a statutory exclusion, providers supplying this test
(directly or through a purchased service) should ensure patients understand
the test is not a covered benefit.

To receive a DNA Specimen Provenance Assay service denial, please submit the
following claim information:

  * CPT code 84999 - unlisted chemistry procedure 
    * 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 service
  * Select the appropriate diagnosis for the patient

If you believe your practice has submitted claims and received reimbursement
in error, you may take the following corrective actions:

  * Complete a Self-Audit 
    * identify incorrect submissions
    * contain further claim submission errors 
  * Consider Self-Disclosure Protocol 
    * self-disclosure guidelines available @ the following pathway:  
http://www.oig.hhs.gov/compliance/self-disclosure-info/index.asp
Billing and Coding: MolDX: LPA-Aspirin Genotype

The MolDX Team has completed a review of the research on the LPA-Aspirin
genotype test, developed to predict increased CVD risk and event reduction
during aspirin therapy. To date, there is insufficient evidence to support the
required clinical utility for the established Medicare benefit category.
Therefore, the LPA-Aspirin genotype test is a statutorily excluded test.

As reviewed, the developer described the indication to perform a LPA-Aspirin
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-Aspirin genotype test would continue to be a statutory
excluded test.

To receive a LPA-Aspirin 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
  * 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
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 
  * 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
Billing and Coding: MolDX: MammaPrint

MammaPrint is a diagnostic test that analyzes the gene expression profile of
FFPE breast cancer tissue samples to assess a patients' risk for distant
metastasis.

The test can be performed using either a FDA-cleared in vitro microarray assay
or a next generation sequencing (NGS)-based assay. Each assay has been
assigned a unique Z-code identifier in the DEX Registry.

MammaPrint was prospectively validated as a microarray assay in the 6,693
patient MINDACT trial in early stage breast cancer, <5cm up to 3 positive
lymph nodes and independent of receptor status. The MammaPrint NGS test has
demonstrated technically equivalent performance to the predicate microarray
test.

To bill for MammaPrint services, please provide the following claim
information:

  * Enter "1" in the Days/Unit field
  * 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. For dates of service on or after 01/01/2022, use CPT code 81523 for the test if performed by NGS.
  * 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

  * Select the appropriate ICD-10-CM codes.

Only one test - NGS OR microarray may be performed on a given date of service
for a given patient.

**Note:** MolDX expects this test may be performed upon occasion twice per
patient lifetime for bilateral disease. Should a patient experience an
additional occurrence, coverage may be considered with supporting
documentation through the appeal process.
Billing and Coding: MolDX: MCOLN1 Genetic Testing

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: 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, the MolDX Team 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
Identifier, 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
    * Item 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: 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, the MolDX Team 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
Identifier, 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 EN
  * 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
      * Item 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

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 Disorder
  * 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
      * Item 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: 
    * SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form