81105 – 81112 Human Platelet Antigen Genotyping No One of the following ICD-10-CM diagnosis codes is required on the claim (except with valid TAR): D69.51 or P61.0 any provider, except with valid TAR override 81120 IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble), common variants No One of the following ICD-10-CM codes is required on the claim (except with valid TAR): C71.0 – C71.9 or C92.00 – C92.02 any provider, except with valid TAR override IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial), common variants No One of the following ICD-10-CM codes is required on the claim (except with valid TAR): C71.0 – C71.9 or C92.00 – C92.02 any provider, except with valid TAR override 81161 DMD (dystrophin) deletion analysis, and duplication analysis, if performed No ICD-10-CM diagnosis code G71.0 (muscular dystrophy) is required on the claim. any provider, except with valid TAR override Once-in-a-
81162 BRCA1, BRCA2 gene analysis; full sequence analysis and full duplication/deletion analysis Continued below Yes A TAR for code requires documentation of one or more of the following numbered criteria. An individual from a family with a known deleterious BRCA mutation; OR Personal history of breast cancer (invasive or ductal carcinoma in situ) plus one or more of the following: Diagnosed at ≤45 years of age; OR Diagnosed at 46 - 50 of age with: An additional breast cancer primary at any age One or more blood relatives with breast cancer at any age One or more close blood relatives with prostate cancer (Gleason score ≥7) An unknown or limited family history; OR Diagnosed at ≤60 years of age with triple negative breast cancer; OR Diagnosed at any age with: One or close blood relatives with: Breast cancer diagnosed at ≤50 years of age; or Ovarian carcinoma; or Male breast cancer; or Metastatic prostate cancer; or Pancreatic cancer Two or more additional diagnosis of breast cancer at any age in patient and/or in close blood relatives; OR Continued any provider, except with valid TAR override * See Attachment B – Family History Screening Tool is suggested for use prior to ordering BRCA testing Note that for the purpose of this policy, a “close blood relative” is defined as a first-degree or second-degree blood relative. First degree relatives are biological parents, siblings, and children. Second-degree relatives are biological grandparents, aunts, uncles, nephews, nieces, grandchildren and half-siblings. Where third degree blood relatives are mentioned, they include great-grandparents, great-aunts, great-grandchildren, and first cousins.
81171 AFF2 (AF4/FMR2 family, member 2 [FMR2]) gene analysis evaluation to detect abnormal alleles No One of the following ICD-10-CM diagnosis codes is required on the claim (except with valid TAR): F70, F71, F80.0 – F89, H93.25, R48.0, R62.0 – R62.59, F82, F88, R48.2 any provider, except with valid TAR override 81172 AFF2 (AF4/FMR2 family, member 2 [FMR2]) gene analysis; characterization of alleles No One of the following ICD-10-CM diagnosis codes is required on the claim (except with valid TAR): F70, F71, F80.0 – F89, H93.25, R48.0, R62.0 – R62.59, F82, F88, R48.2 any provider, except with TAR override 81173 AR (androgen receptor) gene analysis; full gene sequence Yes A TAR for CPT code 81173 requires documentation of the following criteria: The patient has clinical or symptoms suspicious for bulbar muscular atrophy, and The patient requires the service as a confirmatory test for spinal and bulbar muscular atrophy any provider, except with valid TAR override 81174 AR (androgen receptor) gene analysis; known familial variant Yes A TAR for CPT code 81174 requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for bulbar muscular atrophy, and The patient requires the service as a confirmatory test for spinal and bulbar muscular atrophy any provider, except with valid TAR override 81175 ASXL gene analysis, full gene sequence No One of the following ICD-10-CM codes is required on the claim (except with valid TAR): C93.10 – C93.12, D46.0 – D46.C, D47.1 any provider, except with TAR override
81176 ASXL gene analysis, targeted sequence analysis No One of the following ICD-10-CM codes is required on the claim (except with valid TAR): C93.10 – C93.12, D46.0 – D46.C, D47.1 any provider, except with valid TAR override 81177 ATN1 (atrophin 1) gene analysis, evaluation to detect abnormal alleles Yes A TAR for CPT code requires documentation of the following criteria: The patient has clinical or symptoms suspicious for dentatorubral pallidoluysian atrophy, and The patient requires the service as a confirmatory test for dentatorubral pallidoluysian atrophy any provider, except with valid TAR override 81178 ATXN1 (ataxin 1) gene analysis, evaluation to detect abnormal alleles Yes A TAR for CPT code 81178 requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for spinocerebellar ataxia type 1 (SCA1), and The patient requires the service as a confirmatory test for SCA1 any provider, except with valid TAR override 81179 ATXN2 (ataxin 2) gene analysis, evaluation to detect abnormal alleles Yes A TAR for CPT code 81179 requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for spinocerebellar ataxia type 2 (SCA2), and The patient requires the service as a confirmatory test for SCA2 any provider, except with valid TAR override
81184 CACNA1A (calcium channel subunit alpha1 A) gene analysis; evaluation to detect abnormal alleles Yes A TAR for CPT code 81184 requires documentation of the following criteria: The patient has clinical or symptoms suspicious for Episodic ataxia type 2 (EA2), and The patient requires the service as a confirmatory test for EA2 any provider, except with valid TAR override 81185 CACNA1A (calcium channel subunit alpha1 A) gene analysis; full gene sequence Yes A TAR for CPT code 81185 requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for Episodic ataxia type 2 (EA2), and The patient requires the service as a confirmatory test for EA2 any provider, except with valid TAR override 81186 CACNA1A (calcium channel subunit alpha1 A) gene analysis; known familial variant Yes A TAR for CPT code 81186 requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for Episodic ataxia type 2 (EA2), and The patient requires the service as a confirmatory test for EA2 any provider, except with valid TAR override 81187 CNBP (CCHC-type zinc finger nucleic acid binding protein) gene analysis, evaluation to detect abnormal alleles Yes A TAR for CPT code 81187 requires documentation of the following criteria: The patient has clinical or symptoms suspicious for Myotonic dystrophy type 2 (MD2), and The patient requires the service as a confirmatory test for MD2 any provider, except with valid TAR override
81202 APC gene analysis; known familial variants Yes Requires documentation on the Treatment Authorization Request (TAR) of a family history of familial adenomatous polyposis that includes a relative with a known deleterious APC mutation any provider, except with TAR override 81203 APC gene analysis; duplication/deletion variants No One of the following ICD-10-CM codes is required on the claim: C18.0 – C18.9, D12.0 – D12.9, K63.5, Z86.010 any provider, except with valid TAR override 81204 AR (androgen receptor) gene analysis; characterization of alleles Yes A TAR for CPT code requires documentation of the following criteria: The patient has clinical or symptoms suspicious for bulbar muscular atrophy, and The patient requires the service as a confirmatory test for spinal and bulbar muscular atrophy any provider, except with valid TAR override 81206 BCR/ABL1 translocation analysis; major breakpoint No One of the following ICD-10-CM codes is required on the claim: C91.00 – C91.02 or C92.10 – C92.12 1 per month BCR/ABL1 translocation analysis; minor breakpoint No One of the following ICD-10-CM codes is required on the claim: C91.00 – C91.02 or C92.10 – C92.12 1 per 81208 BCR/ABL1 translocation analysis; other breakpoint No One of the following ICD-10-CM is required on the claim: C91.00 – C91.02 or C92.10 – C92.12 1 per
81210 BRAF (B-Raf serine/threonine kinase), gene analysis, V600 variant(s) No One of the following ICD-10-CM codes is required on the claim: C18.0 – C18.9, C19, C20, C43.0 – C43.9, C79.2 or D03.0 – D03.9 any provider, except with valid TAR override 81212 BRCA1, BRCA2 gene analysis; variants Yes Requires documentation on the TAR of the following: An individual is of an ethnicity associated with the Ashkenazi Jewish population No additional family history may be required any provider, except with valid TAR override See Attachment B - Family History Screening Tool which is suggested for use prior to ordering BRCA testing 81215 BRCA1 (breast cancer 1) gene analysis; known familial variant Yes See CPT code for TAR criteria and billing requirements. See CPT code 81162 81216 BRCA2 (breast cancer 2) gene analysis; full sequence analysis Yes See CPT code 81162 for TAR criteria and billing requirements. See CPT code 81162 81217 BRCA2 (breast cancer 2) gene analysis; known familial variant Yes See CPT code 81162 for TAR criteria and billing requirements. See CPT code 81218 (CCAAT/enhancer binding protein [C/EBP], alpha) gene analysis, full gene sequence No One of the following ICD-10-CM codes is required on the claim: C92.00 – C92.02, C92.40 – C92.42 or C92.50 – C92.52 any provider, except with valid TAR override
81235 EGFR (epidermal growth factor receptor) gene analysis, common variants No One of the following ICD-10-CM codes is required on the claim: C33, C34.00 – C34.92 any provider, except with valid TAR override 81236 EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) gene analysis, full gene sequence No One of the following ICD-10-CM codes is required on the claim (except with valid TAR): D47.1, D47.3, C83.30 – C83.39 Not more than once per month 81237 EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) gene analysis, common variant(s) No One of the following ICD-10-CM codes is required on the claim (except with valid TAR): D47.1, D47.3, C83.30 – C83.39 Not more than once per month 81238 F9 (coagulation factor IX) full gene analysis sequence No ICD-10-CM code D67 is required on the claim (except with valid TAR) any provider, except with TAR override 81239 DMPK (DM1 protein kinase) gene analysis; characterization of alleles Yes A TAR for CPT code requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for myotonic dystrophy type 1 (MD1), and The patient requires the service as a diagnostic test for MD1. any provider, except with valid TAR override
81243 FMR1 (fragile X mental retardation 1) gene analysis; evaluation to detect abnormal alleles No One of the following ICD-10-CM codes is required on the claim: F70, F71 – F73, F78, F80.0 – F84.2, F88, F89, H93.25, R48.2, R62.0, R62.50 – R62.59 any provider, except with valid TAR override 81244 FMR1 (fragile X mental retardation 1) gene analysis; characterization of alleles No One of the following ICD-10-CM codes is required on the claim: F70, F71 – F73, F78, F80.0 – F84.2, F88, F89, H93.25, R48.2, R62.0, R62.50 – R62.59 any provider, except with valid TAR override 81245 FLT3 (fms-related tyrosine kinase 3), gene analysis; internal tandem duplication (ITD) variants No One of the following ICD-10-CM codes is required on the claim: C92.00 – C92.02, C92.60 - C92.62 or C92.A0 any provider, except with valid TAR override FLT3 (fms-related tyrosine kinase 3), gene analysis; tyrosine kinase domain (TKD) variants No One of the following ICD-10-CM codes is required on the claim: C92.00 – C92.02, C92.60 - C92.62 or C92.A0 – C92.A2 any provider, except with valid TAR override G6PC catalytic subunit) gene analysis, common variants Yes The patient has clinical features suspicious for, or requires the laboratory service as a diagnostic test for glycogen storage disease, type 1a any provider, except with valid TAR override
81256 HFE (hemochromatosis) gene analysis, common variants No One of the following ICD-10-CM codes is required on the claim: E83.10, E83.110 or E83.118 – E83.119 any provider, except with TAR override 81257 HBA1/HBA2 globin 1 and alpha globin 2), gene analysis; common deletions or variant No N/A Lifetime, any provider, except with valid TAR override 81258 HBA1/HBA2 (alpha globin 1 and alpha globin 2), gene analysis; known familial variant No N/A any provider, except with valid TAR override 81259 HBA1/HBA2 (alpha globin 1 and alpha globin 2), gene analysis; full gene sequence Yes N/A any provider, except with valid TAR override
81260 IKBKAP (inhibitor of light polypeptide gene enhancer in B-cells, kinas complex-associated protein) gene analysis, common variants No Indicated for: Hypotonia in infancy Decreased or absent deep tendon reflexes Decreased taste and absence of fungiform papillae of the tongue Absence of overflow tears with emotional crying (alacrima) Absence of axon flare response after intradermal histamine injection Pupillary hypersensitivity to parasympathomimetic agents any provider, except with valid TAR override While DHCS requires a TAR for this test, PHC has chosen to have no TAR requirement. 81265 Comparative analysis Short Tandem Repeat markers No One of the following ICD-10-CM is required on the claim: C81.00 – C96.9, D45, T86.00 – T86.09 or T86.5 any provider, except with valid TAR override 81266 Comparative analysis using Short Tandem Repeat markers; each additional specimen No One of the following ICD-10-CM codes is required on the claim: C81.00 – C96.9, D45, T86.00 – T86.09 or T86.5 any provider, except with valid TAR override 81267 Chimerism (engraftment) analysis, post transplantation specimen; without cell selection No One of the following ICD-10-CM codes is required on the claim: T86.01, T86.02, T86.09 or T86.5 1 per month
KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), gene analysis, targeted sequence analysis No One of the following ICD-10-CM codes is required on the claim: C43.70 - C43.72, C92.00 – C92.02, C92.40 – C92.42, C92.50 – C92.52, D03.70 – D03.72 or D48.1 any provider, except with valid TAR override 81273 KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), gene analysis, D816 variant(s) No One of the following ICD-10-CM is required on the claim: C96.20 – C96.29 any provider, except with TAR override HTT (huntingtin) gene analysis; characterization of alleles Yes A TAR for CPT code 81274 requires documentation of the following criteria: For adults, the patient has unequivocal signs of Huntington’s disease (HD) and requires the service to confirm the diagnosis For children, the patient has a family history of HD and develops symptoms that raise the suspicion for juvenile-onset HD as exemplified by two or more of the following: Declining school performance Seizures Oral motor dysfunction Rigidity Gait disturbance any provider, except with valid TAR override 81275 KRAS (Kirsten rat sarcoma viral oncogene homolog) gene analysis; variants in exon 2 No One of the following ICD-10-CM is required on the claim: C18.0 – C20, D01.1, D01.2, D01.40, D01.49, D37.4 or D37.5 any provider, except with valid TAR override
KRAS (Kristen rat sarcoma viral oncogene homolog) gene analysis; additional variant(s) No One of the following ICD-10-CM is required on the claim: C18.0, C18.2 – C20, D01.1, D01.2, D01.40, D01.49, D37.4 or D37.5 any provider, except with valid TAR override 81283 IFNL3 (interferon, lambda 3), gene analysis, rs12979860 variant No ICD-10-CM code B18.2 is required on the claim (except with valid TAR) any provider, except with valid TAR override 81284 FXN (frataxin) gene analysis; evaluation to detect abnormal alleles Yes A TAR for CPT code requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for Friedreich ataxia (FRDA), and The patient requires the service as a confirmatory test for FRDA any provider, except with valid TAR override 81285 FXN (frataxin) gene analysis; characterization of alleles Yes A TAR for CPT code 81285 requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for Friedreich ataxia (FRDA), and The patient requires the service as a confirmatory test for FRDA any provider, except with valid TAR override
81286 FXN (frataxin) gene analysis; full gene sequence Yes A TAR for CPT code requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for Friedreich ataxia (FRDA), and The patient requires the service as a confirmatory test for FRDA any provider, except with valid TAR override 81287 MGMT (0-6 methyltransferase) methylation analysis No Indicated for: The patient has the diagnosis of glioblastoma multiforme, and Treatment strategy will be contingent on the test results Reimbursable when billed with ICD-10 : C71.9. any provider, except with valid TAR override While DHCS requires a TAR for this test, PHC has chosen to have no TAR requirement when billed with ICD-10 code C71.9 81288 MLH1 gene analysis; promoter methylation analysis Yes Document the following criteria on the TAR: Patient with cancer, and The tumor demonstrates microsatellite instability or immunohistochemistry results indicating loss of MLH1 protein expression any provider, except with TAR override 81289 FXN (frataxin) gene analysis; known familial variant(s) Yes A TAR for CPT code 81289 requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for Friedreich ataxia (FRDA), and The patient requires the service as a confirmatory test for FRDA any provider, except with valid TAR override 81292 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) gene analysis; full sequence analysis No One of the following ICD-10-CM codes is required on the claim: C17.0 – C20, C24.0 – C25.9, C54.0 – C54.9, C65.1 – C66.9, C71.0 – C71.9, D23.0 – D23.9, Z80.0, Z80.49, Z85.030, Z85.038, Z85.040, Z85.048, Z85.42 any provider, except with valid TAR override
81306 NUDT15 hydrolase 15) gene analysis, common variant(s) Yes A TAR for CPT code 81306 requires documentation of the following criteria: The patient is undergoing thiopurine therapy, and The patient has severe or prolonged myelosuppression. any provider, except with valid TAR override 81310 NPM1 (nucleophosmin) gene analysis, exon 12 variants No One of the following ICD-10-CM codes is required on the claim: C92.00 – C92.02 any provider, except with valid TAR override NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) gene analysis, variants in exon 2 and exon 3 No One of the following ICD-10-CM codes is required on the claim: C18.0, C18.2 – C20, D01.1, D01.2, D01.40, D01.49, D37.4 or D37.5 any provider, except with valid TAR override 81312 PABPN1 (poly[A] binding protein nuclear 1) gene analysis, evaluation to detect abnormal alleles Yes A TAR for CPT code requires documentation of the following criteria: The patient has symptoms of ptosis and dysphagia, and The patient requires the service as a confirmatory test for Oculopharyngeal Muscular Dystrophy any provider, except with valid TAR override 81314 PDGFRA (platelet-derived growth factor receptor, alpha polypeptide), gene analysis, targeted sequence analysis No ICD-10-CM code D48.1 is required on the any provider, except with valid TAR override
Continued from above 81321 PTEN (phosphatase and tensin homolog) gene analysis; full sequence analysis Continued Yes Mental retardation (IQ ≤75) Autism spectrum disorder Single GI tract hamartoma or ganglioneuroma Fibrocystic disease of the breast Lipomas Fibromas Renal cell carcinoma Uterine fibroids any provider, except with valid TAR override 81322 PTEN gene analysis; known familial variant Yes Requires documentation on the TAR that patient is from a family with a known PTEN mutation any provider, except with valid TAR override PTEN gene analysis; duplication/deletion variant Yes Requires documentation on the TAR of a negative result in the full sequence analysis in PTEN (CPT-4 code and that patient meets one or more criteria listed under code 81321 any provider, except with valid TAR override 81329 SMN1 (survival of motor neuron 1, telomeric) gene analysis; dosage/deletion analysis, includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed Yes A TAR for CPT code 81329 requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for spinal muscular atrophy, and The patient requires the service as a confirmatory test for spinal muscular atrophy any provider, except with valid TAR override
81337 SMN1 (survival of motor neuron 1, telomeric) gene analysis; known familial sequence variant(s) Yes A TAR for CPT code 81337 requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for spinal muscular atrophy, and The patient requires the service as a confirmatory test for spinal muscular atrophy any provider, except with valid TAR override 81343 PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) gene analysis, evaluation to detect abnormal alleles Yes A TAR for CPT code 81343 requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for spinocerebellar ataxia type 12 (SCA12), and The patient requires the service as a confirmatory test for any provider, except with valid TAR override 81344 TBP (TATA box binding protein) gene analysis, evaluation to detect abnormal alleles Yes A TAR for CPT code 81344 requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for spinocerebellar ataxia type 17 (SCA17), and The patient requires the service as a confirmatory test for SCA17 any provider, except with TAR override 81345 TERT (telomerase reverse transcriptase) gene analysis, targeted sequence analysis Yes Document the following criteria on the TAR: The patient has the diagnosis of II, III or IV glioma. any provider, except with valid TAR override 81361 HBB (hemoglobin, subunit beta); common variant(s) (eg, HbS, HbC, HbE) No N/A any provider, except with valid TAR override
81362 HBB (hemoglobin, subunit beta); known familial variant(s) No N/A any provider, except with valid TAR override 81363 HBB (hemoglobin, subunit beta); duplication/deletion variant(s) No N/A any provider, except with valid TAR override HBB (hemoglobin, subunit beta); full gene sequence No N/A any provider, except with valid TAR override 81370 – 81383 Human Leukocyte Antigen Typing No TAR required CPT-4 81370 – 81380, 81382 and 81383 (human leukocyte antigen typing) are reimbursable only with an ICD-10-CM diagnosis in the range of Z94.0 – Z94.9. CPT-4 code 81381 (HLA Class I typing, high resolution, one allele or allele group, each) is only reimbursable with an ICD-10-CM diagnosis of B20, F31.0 – F31.9, G40.001 – G40.919, G50.0, R75, Z01.812, Z21, Z94.0 – Z94.9. any provider, except with TAR override
Continued below Continued from above 81403 Molecular Pathology Procedure, 4 Yes The patient is under evaluation for surgical intervention For suspected developmental delay, epilepsy and neonatal diabetes (DEND) syndrome: The patient has developmental delay, epilepsy and neonatal diabetes The confirmation of the diagnosis and the treatment strategy is contingent on the test result KIR (killer cell immunoglobulin-like receptor for hematopoietic stem cell transplantation): The patient has diagnosis of acute myeloid leukemia, and The test is used for donor search process for patients considering hematopoietic stem cell transplantation Known family variant not otherwise specified, for gene listed in Molecular Pathology Procedure Levels 1 - 3 or identified during a genomic sequencing procedure (GSP), DNA sequence analysis, each variant exon: Documentation of the specific gene listed in Molecular Pathology Procedure Levels 1 - 3 or GSP for which further analysis is being requested MICA (solid organ transplantation): The patient is undergoing evaluation for kidney transplantation, or The patient is post kidney transplantation any provider, except with TAR override
Continued from above 81405 Molecular Pathology Procedure, Level 6 Continued Yes reimbursable for one of the following numbered criteria: 1) All of the following conditions: The patient has sarcoma diagnosed before 45 years of age, and A first-degree relative with any cancer before 45 years of age, and A first or second-degree relative with any cancer before 45 years of age, or a sarcoma at any age; or 2) All of the following conditions: A belonging to the Li-Fraumeni Syndrome (LFS) tumor spectrum (soft tissue sarcoma, osteosarcoma, breast cancer, brain tumor, adrenocortical carcinoma, leukemia or lung bronchoalveolar cancer) before 46 years of age, and At least one first or second-degree relative with an LFS tumor (except breast cancer if the patient has breast cancer) before 56 years of age or with multiple tumors; or 3) The patient has multiple tumors (except multiple breast tumors), two of belong to the LFS tumor spectrum, and the first occurred before 46 years of age; or 4) The patient is diagnosed with adrenocortical carcinoma or choroid plexus tumor. WT1 (Wilms tumor 1) – full gene sequence – The patient has suspected or confirmed acute myeloid leukemia, and the result of the test will any provider, except with valid TAR override
81407 Molecular Pathology Procedure, Level 8 Continued Yes Continued Coverage for CPT-4 code 81407 (molecular pathology procedure, Level 8) is limited to the listed services. Reimbursement for code 81407 requires an approved TAR and requires providers to document one of the following on the TAR: (familial hyperinsulinism): The patient has persistent hyperinsulinemic hypoglycemia of infancy (PHHI) who failed medical therapy, and The patient is under evaluation for surgical intervention AGL (glycogen storage disease type III) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for glycogen storage disease type III any provider, except with valid TAR override
Molecular Pathology Procedure, Level 8 Yes JAG1 (Alagille syndrome) – full gene sequence – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Alagille syndrome NOTCH (notch 1) – full gene sequence – The patient has suspected or confirmed acute lymphoblastic leukemia, and the result of the test will influence the diagnosis, prognosis and/or therapeutic management NPHS1 (congenital Finnish nephrosis) The patient has clinical diagnosis of steroid-resistant nephritic syndrome (SRNS)/congenital Finnish nephrosis, and Treatment will be contingent on the test results SCN1A – The patient has clinical features suspicious for, or requires the service as a confirmatory test for Dravet syndrome SPTBN2 (spinocerebellar ataxia) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinocerebellar ataxia Claims without documentation showing the preceding criteria have been met will be denied. any provider, except with valid TAR override
81420 and 81507 Testing for Fetal Aneuploidy - Cell Free Fetal DNA Testing No Diagnosis required for payment: Z33.x, Z34.x, Z3A.xx, O09.x, O2x.x Payable no more than once every 9 months (once per pregnancy) 81435, 81436 Genomic Sequencing Procedures: Hereditary Colon Cancer Disorders No TAR required when CPT codes listed are billed Reimbursement for CPT-4 codes 81435 (hereditary colon cancer disorders; genomic sequence analysis panel, must include analysis of at least 10 genes, including APC, BMPR1A, CDH1, MLH1, MSH2, MSH6, MUTYH, PTEN, SMAD4 and STK11) and 81436 (…duplication/deletion analysis panel, must include analysis of at least 5 genes, including MLH1, MSH2, EPCAM, SMAD4, and STK11) is limited to once-in-a-lifetime. 81435 and 81436 are reimbursable only when billed in conjunction with one of the following diagnosis codes: C17.0 – C20, C24.0 – C25.9, C54.0 – C54.9, C65.1 – C66.9, C71.0 – C71.9, D23.0 – D23.9, Z80.0, Z80.49, Z85.030 - Z85.038, Z85.040 - Z85.048, Z85.42, Z86.010 any provider, except with valid TAR override While DHCS requires a TAR for this test, PHC has chosen to have no TAR requirement.
81528 Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result No Reimbursable for recipients 50 – 75 of age. For recipients outside this age range, providers must submit a TAR documenting medical necessity. * For recipients requiring additional tests within a year, providers must submit a TAR documenting medical necessity. No more than once every two years * 81545 Multianalyte Assays With Algorithmic Analyses Yes Oncology, when billed with CPT-4 code 81545 (oncology with Algorithmic Analyses [thyroid], gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as a categorical result) requires a TAR and has a frequency limit. The following criteria must be documented on the TAR: Thyroid nodule that is cytologically indeterminate on fine-needle aspiration The diagnostic or treatment strategy will be contingent on test results any provider, except with valid TAR override 81520, 81521, 81599 Gene Expression Profiling for Breast Cancer Continued Yes Gene expression profiling for breast cancer may be billed with CPT-4 code 81518 (oncology [breast], mRNA, gene expression profiling by real time of 11 genes, utilizing formalin-fixed tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy), 81519 (oncology [breast], mRNA, gene expression profiling by real time RT-PCR of 21 embedded As noted