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12437 Results

Genetic Testing - Gene Expression

Service Code
81522 (CPT) Oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes (8 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk score
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Gene expression refers to the mechanism through which the genetic information stored in a gene is transformed into a functional outcome. This predominantly transpires by transcribing RNA molecules that encode proteins or non-coding RNA molecules with alternative roles. Gene expression can be likened to an "on off switch," determining the timing and location of RNA molecules and proteins production, and a "volume control," dictating the quantity of these products generated. The process of gene expression is meticulously regulated and undergoes significant changes based on various conditions and cell types. Numerous RNA and protein products derived from genes play a role in governing the expression of other genes. The extent, timing, and manner in which a gene is expressed can be evaluated by assessing the functional activity of its product or observing the phenotype associated with the gene

Authorization Guidelines

See Evicore site for specific requirements

Reauthorization Guidelines

See Evicore site for specific requirements

Limits

Medicaid shall not cover whole exome sequencing (WES) or whole genome sequencing (WGS) for ANY of the following scenarios:

  • 1. When the CCP criteria are not met;
  • 2. For uncomplicated autism spectrum disorder, developmental delay, and

mild to moderate global developmental delay;

  • 3. For screening during pregnancy to diagnose fetal conditions;
  • 4. For testing an embryo before implantation;
  • 5. For screening genetic carriers;
  • 6. Genetic disorders in every other circumstance; or
  • 7. The test is used to determine ancestry.

Comparator genome sequence analysis requires that whole genome sequencing be performed simultaneously or have been previously performed. For whole genome sequencing beneficiary must be currently admitted to or recently discharged from a NICU or PICU

Length of Stay

Once each primary cancer occurrence

Exclusions

Breast cancer gene expression profiling is not covered when CCP Specific criteria are not met or when used to predict response to specific chemotherapy regimens, for known metastatic cancer, for ductal carcinoma in situ when DCIS is the sole breast cancer histology, for the same tumor or more than one site when the primary tumor is multifocal, or to determine risk after the beneficiary has already decided to undergo or forego chemotherapy. Breast cancer management testing is also not covered when a gene expression profiling test other than the specified covered assays is used.

Thyroid nodule gene expression profiling is not covered when the additional criteria in the CCP are not met.

AlloMap is not covered for beneficiaries with a history of antibody-mediated rejection, for uses outside heart transplant rejection monitoring, or when results would not affect clinical management such as when a biopsy is already planned based on other risk factors.

Age Group Details

Thyroid nodule gene expression profiling is limited to beneficiaries age 21 years and older.

AlloMap molecular expression testing is limited to beneficiaries age 15 years and older.

Place of Service

Inpatient, Outpatient, Office, Laboratory.

How to Submit

Please submit your request to EviCore

Resources

Genetic Testing - Gene Expression

Service Code
81523 (CPT) Oncology (breast), mRNA, next-generation sequencing gene expression profiling of 70 content genes and 31 housekeeping genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk to distant metastasis
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Gene expression refers to the mechanism through which the genetic information stored in a gene is transformed into a functional outcome. This predominantly transpires by transcribing RNA molecules that encode proteins or non-coding RNA molecules with alternative roles. Gene expression can be likened to an "on off switch," determining the timing and location of RNA molecules and proteins production, and a "volume control," dictating the quantity of these products generated. The process of gene expression is meticulously regulated and undergoes significant changes based on various conditions and cell types. Numerous RNA and protein products derived from genes play a role in governing the expression of other genes. The extent, timing, and manner in which a gene is expressed can be evaluated by assessing the functional activity of its product or observing the phenotype associated with the gene

Authorization Guidelines

See Evicore site for specific requirements

Reauthorization Guidelines

See Evicore site for specific requirements

Limits

Medicaid shall not cover whole exome sequencing (WES) or whole genome sequencing (WGS) for ANY of the following scenarios:

  • 1. When the CCP criteria are not met;
  • 2. For uncomplicated autism spectrum disorder, developmental delay, and

mild to moderate global developmental delay;

  • 3. For screening during pregnancy to diagnose fetal conditions;
  • 4. For testing an embryo before implantation;
  • 5. For screening genetic carriers;
  • 6. Genetic disorders in every other circumstance; or
  • 7. The test is used to determine ancestry.

Comparator genome sequence analysis requires that whole genome sequencing be performed simultaneously or have been previously performed. For whole genome sequencing beneficiary must be currently admitted to or recently discharged from a NICU or PICU

Length of Stay

Once each primary cancer occurrence

Exclusions

Breast cancer gene expression profiling is not covered when CCP Specific criteria are not met or when used to predict response to specific chemotherapy regimens, for known metastatic cancer, for ductal carcinoma in situ when DCIS is the sole breast cancer histology, for the same tumor or more than one site when the primary tumor is multifocal, or to determine risk after the beneficiary has already decided to undergo or forego chemotherapy. Breast cancer management testing is also not covered when a gene expression profiling test other than the specified covered assays is used.

Thyroid nodule gene expression profiling is not covered when the additional criteria in the CCP are not met.

AlloMap is not covered for beneficiaries with a history of antibody-mediated rejection, for uses outside heart transplant rejection monitoring, or when results would not affect clinical management such as when a biopsy is already planned based on other risk factors.

Age Group Details

Thyroid nodule gene expression profiling is limited to beneficiaries age 21 years and older.

AlloMap molecular expression testing is limited to beneficiaries age 15 years and older.

Place of Service

Inpatient, Outpatient, Office, Laboratory.

How to Submit

Please submit your request to EviCore

Resources

Oncology (central nervous system tumor), DNA methylation analysis of at least 10,000 methylation sites, utilizing DNA extracted from formalin-fixed tumor tissue, algorithm(s) reported as probability of matching a reference tumor family and class, and MGMT (O-6-methylguanine-DNA methyltransferase) promoter methylation status, if performed

Service Code
81524 (CPT) Oncology (central nervous system tumor), DNA methylation analysis of at least 10,000 methylation sites, utilizing DNA extracted from formalin-fixed tumor tissue, algorithm(s) reported as probability of matching a reference tumor family and class, and MGMT (O-6-methylguanine-DNA methyltransferase) promoter methylation status, if performed
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

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

Service Code
81525 (CPT) 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
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

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

Service Code
81528 (CPT) 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
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis

Service Code
81529 (CPT) Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

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

Service Code
81535 (CPT) 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
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

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 pr

Service Code
81536 (CPT) 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 pr
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival

Service Code
81538 (CPT) Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

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

Service Code
81539 (CPT) 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
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

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

Service Code
81540 (CPT) 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
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

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

Service Code
81541 (CPT) 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
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score

Service Code
81542 (CPT) Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Genetic Testing - Gene Expression

Service Code
81546 (CPT) Oncology (thyroid), mRNA, gene expression analysis of 10,196 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (eg, benign or suspicious)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Gene expression refers to the mechanism through which the genetic information stored in a gene is transformed into a functional outcome. This predominantly transpires by transcribing RNA molecules that encode proteins or non-coding RNA molecules with alternative roles. Gene expression can be likened to an "on off switch," determining the timing and location of RNA molecules and proteins production, and a "volume control," dictating the quantity of these products generated. The process of gene expression is meticulously regulated and undergoes significant changes based on various conditions and cell types. Numerous RNA and protein products derived from genes play a role in governing the expression of other genes. The extent, timing, and manner in which a gene is expressed can be evaluated by assessing the functional activity of its product or observing the phenotype associated with the gene

Authorization Guidelines

See Evicore site for specific requirements

Reauthorization Guidelines

See Evicore site for specific requirements

Limits

Medicaid shall not cover whole exome sequencing (WES) or whole genome sequencing (WGS) for ANY of the following scenarios:

  • 1. When the CCP criteria are not met;
  • 2. For uncomplicated autism spectrum disorder, developmental delay, and

mild to moderate global developmental delay;

  • 3. For screening during pregnancy to diagnose fetal conditions;
  • 4. For testing an embryo before implantation;
  • 5. For screening genetic carriers;
  • 6. Genetic disorders in every other circumstance; or
  • 7. The test is used to determine ancestry.

Comparator genome sequence analysis requires that whole genome sequencing be performed simultaneously or have been previously performed. For whole genome sequencing beneficiary must be currently admitted to or recently discharged from a NICU or PICU

Length of Stay

Once each primary cancer occurrence

Exclusions

Breast cancer gene expression profiling is not covered when CCP Specific criteria are not met or when used to predict response to specific chemotherapy regimens, for known metastatic cancer, for ductal carcinoma in situ when DCIS is the sole breast cancer histology, for the same tumor or more than one site when the primary tumor is multifocal, or to determine risk after the beneficiary has already decided to undergo or forego chemotherapy. Breast cancer management testing is also not covered when a gene expression profiling test other than the specified covered assays is used.

Thyroid nodule gene expression profiling is not covered when the additional criteria in the CCP are not met.

AlloMap is not covered for beneficiaries with a history of antibody-mediated rejection, for uses outside heart transplant rejection monitoring, or when results would not affect clinical management such as when a biopsy is already planned based on other risk factors.

Age Group Details

Thyroid nodule gene expression profiling is limited to beneficiaries age 21 years and older.

AlloMap molecular expression testing is limited to beneficiaries age 15 years and older.

Place of Service

Inpatient, Outpatient, Office, Laboratory.

How to Submit

Please submit your request to EviCore

Resources

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

Service Code
81551 (CPT) 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
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Oncology (uveal melanoma), mRNA, gene expression profiling by real-time RT-PCR of 15 genes (12 content and 3 housekeeping), utilizing fine needle aspirate or formalin-fixed paraffin-embedded tissue, algorithm reported as risk of metastasis

Service Code
81552 (CPT) Oncology (uveal melanoma), mRNA, gene expression profiling by real-time RT-PCR of 15 genes (12 content and 3 housekeeping), utilizing fine needle aspirate or formalin-fixed paraffin-embedded tissue, algorithm reported as risk of metastasis
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categorical result (eg, positive or negative for high probability of usual interstitial pneumonia [UIP])

Service Code
81554 (CPT) Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categorical result (eg, positive or negative for high probability of usual interstitial pneumonia [UIP])
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Transplantation medicine (allograft rejection, kidney), mRNA, gene expression profiling by quantitative polymerase chain reaction (qPCR) of 139 genes, utilizing whole blood, algorithm reported as a binary categorization as transplant excellence, which indicates immune quiescence, or not transplant excellence, indicating subclinical rejection

Service Code
81558 (CPT) Transplantation medicine (allograft rejection, kidney), mRNA, gene expression profiling by quantitative polymerase chain reaction (qPCR) of 139 genes, utilizing whole blood, algorithm reported as a binary categorization as transplant excellence, which indicates immune quiescence, or not transplant excellence, indicating subclinical rejection
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Genetic Testing - Gene Expression

Service Code
81595 (CPT) 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
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Gene expression refers to the mechanism through which the genetic information stored in a gene is transformed into a functional outcome. This predominantly transpires by transcribing RNA molecules that encode proteins or non-coding RNA molecules with alternative roles. Gene expression can be likened to an "on off switch," determining the timing and location of RNA molecules and proteins production, and a "volume control," dictating the quantity of these products generated. The process of gene expression is meticulously regulated and undergoes significant changes based on various conditions and cell types. Numerous RNA and protein products derived from genes play a role in governing the expression of other genes. The extent, timing, and manner in which a gene is expressed can be evaluated by assessing the functional activity of its product or observing the phenotype associated with the gene

Authorization Guidelines

See Evicore site for specific requirements

Reauthorization Guidelines

See Evicore site for specific requirements

Limits

Medicaid shall not cover whole exome sequencing (WES) or whole genome sequencing (WGS) for ANY of the following scenarios:

  • 1. When the CCP criteria are not met;
  • 2. For uncomplicated autism spectrum disorder, developmental delay, and

mild to moderate global developmental delay;

  • 3. For screening during pregnancy to diagnose fetal conditions;
  • 4. For testing an embryo before implantation;
  • 5. For screening genetic carriers;
  • 6. Genetic disorders in every other circumstance; or
  • 7. The test is used to determine ancestry.

Comparator genome sequence analysis requires that whole genome sequencing be performed simultaneously or have been previously performed. For whole genome sequencing beneficiary must be currently admitted to or recently discharged from a NICU or PICU

Length of Stay

Once each primary cancer occurrence

Exclusions

Breast cancer gene expression profiling is not covered when CCP Specific criteria are not met or when used to predict response to specific chemotherapy regimens, for known metastatic cancer, for ductal carcinoma in situ when DCIS is the sole breast cancer histology, for the same tumor or more than one site when the primary tumor is multifocal, or to determine risk after the beneficiary has already decided to undergo or forego chemotherapy. Breast cancer management testing is also not covered when a gene expression profiling test other than the specified covered assays is used.

Thyroid nodule gene expression profiling is not covered when the additional criteria in the CCP are not met.

AlloMap is not covered for beneficiaries with a history of antibody-mediated rejection, for uses outside heart transplant rejection monitoring, or when results would not affect clinical management such as when a biopsy is already planned based on other risk factors.

Age Group Details

Thyroid nodule gene expression profiling is limited to beneficiaries age 21 years and older.

AlloMap molecular expression testing is limited to beneficiaries age 15 years and older.

Place of Service

Inpatient, Outpatient, Office, Laboratory.

How to Submit

Please submit your request to EviCore

Resources

Infectious disease, chronic hepatitis C virus (HCV) infection, six biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, and haptoglobin) utilizing serum, prognostic algorithm reported as scores for fibrosis and necroinflamm

Service Code
81596 (CPT) Infectious disease, chronic hepatitis C virus (HCV) infection, six biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, and haptoglobin) utilizing serum, prognostic algorithm reported as scores for fibrosis and necroinflamm
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore