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Provider Support Service Line: 1-855-250-1539

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12437 Results

Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having recurrent urothelial carcinoma

Service Code
0013M (CPT) Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having recurrent urothelial carcinoma
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 (bladder), mRNA, microarray gene expression profiling of 219 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like)

Service Code
0016M (CPT) Oncology (bladder), mRNA, microarray gene expression profiling of 219 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like)
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 (diffuse large B-cell lymphoma [DLBCL]), mRNA, gene expression profiling by fluorescent probe hybridization of 20 genes, formalin-fixed paraffin-embedded tissue, algorithm reported as cell of origin

Service Code
0017M (CPT) Oncology (diffuse large B-cell lymphoma [DLBCL]), mRNA, gene expression profiling by fluorescent probe hybridization of 20 genes, formalin-fixed paraffin-embedded tissue, algorithm reported as cell of origin
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
0018U (CPT) Oncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to high risk of malignancy
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

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

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

Cardiovascular disease, plasma, analysis of protein biomarkers by aptamer-based microarray and algorithm reported as 4-year likelihood of coronary event in high-risk populations

Service Code
0019M (CPT) Cardiovascular disease, plasma, analysis of protein biomarkers by aptamer-based microarray and algorithm reported as 4-year likelihood of coronary event in high-risk populations
Prior Authorization Required
No
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

N/A - No authorization is required

Oncology, RNA, gene expression by whole transcriptome sequencing, formalin-fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agents

Service Code
0019U (CPT) Oncology, RNA, gene expression by whole transcriptome sequencing, formalin-fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agents
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 (central nervous system), analysis of 30000 DNA methylation loci by methylation array, utilizing DNA extracted from tumor tissue, diagnostic algorithm reported as probability of matching a reference tumor subclass

Service Code
0020M (CPT) Oncology (central nervous system), analysis of 30000 DNA methylation loci by methylation array, utilizing DNA extracted from tumor tissue, diagnostic algorithm reported as probability of matching a reference tumor subclass
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 for Diagnosis and Treatment

Service Code
0022U (CPT) Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence/absence of variants and associated therapy(ies) to consider
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.

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.

Reauthorization Guidelines

See Evicore site for specific requirements

Limits

once in a lifetime

Place of Service

Inpatient, Outpatient, Office, Laboratory

How to Submit

Please submit your request to EviCore

Resources

Glycosylated acute phase proteins (GlycA), nuclear magnetic resonance spectroscopy, quantitative

Service Code
0024U (CPT) Glycosylated acute phase proteins (GlycA), nuclear magnetic resonance spectroscopy, quantitative
Prior Authorization Required
No
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

N/A - No authorization is required

Tenofovir, by liquid chromatography with tandem mass spectrometry (LC-MS/MS), urine, quantitative

Service Code
0025U (CPT) Tenofovir, by liquid chromatography with tandem mass spectrometry (LC-MS/MS), urine, quantitative
Prior Authorization Required
No
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

N/A - No authorization is required

Genetic Testing - Gene Expression

Service Code
0026U (CPT) Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result ("Positive, high probability of malignancy" or "Negative, low probability of malignanc
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

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

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

Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs12777823)

Service Code
0029U (CPT) Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs12777823)
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

Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823)

Service Code
0030U (CPT) Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823)
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

CYP1A2 (cytochrome P450 family 1, subfamily A, member 2)(eg, drug metabolism) gene analysis, common variants (ie, *1F, *1K, *6, *7)

Service Code
0031U (CPT) CYP1A2 (cytochrome P450 family 1, subfamily A, member 2)(eg, drug metabolism) gene analysis, common variants (ie, *1F, *1K, *6, *7)
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

COMT (catechol-O-methyltransferase)(drug metabolism) gene analysis, c.472G>A (rs4680) variant

Service Code
0032U (CPT) COMT (catechol-O-methyltransferase)(drug metabolism) gene analysis, c.472G>A (rs4680) variant
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

TPMT (thiopurine S-methyltransferase), NUDT15 (nudix hydroxylase 15)(eg, thiopurine metabolism) gene analysis, common variants (ie, TPMT *2, *3A, *3B, *3C, *4, *5, *6, *8, *12; NUDT15 *3, *4, *5)

Service Code
0034U (CPT) TPMT (thiopurine S-methyltransferase), NUDT15 (nudix hydroxylase 15)(eg, thiopurine metabolism) gene analysis, common variants (ie, TPMT *2, *3A, *3B, *3C, *4, *5, *6, *8, *12; NUDT15 *3, *4, *5)
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

Neurology (prion disease), cerebrospinal fluid, detection of prion protein by quaking-induced conformational conversion, qualitative

Service Code
0035U (CPT) Neurology (prion disease), cerebrospinal fluid, detection of prion protein by quaking-induced conformational conversion, qualitative
Prior Authorization Required
No
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

N/A - No authorization is required

Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence analyses

Service Code
0036U (CPT) Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence analyses
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

1S-12, Genetic Testing - Next Generation Sequencing (NGS)

Service Code
0037U (CPT) Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Next-generation sequencing, also referred to as next-gen sequencing, has revolutionized genetic research and healthcare by enabling the identification of genetic variations. This innovative technique involves determining the sequence of nucleotides, the building blocks of DNA, in a beneficiary’s genetic code, which is known as DNA sequencing. Two commonly employed methods, namely whole exome sequencing and whole genome sequencing, leverage advanced technologies that enable the rapid sequencing of substantial amounts of DNA. These approaches have significantly propelled the field of genetics and serve as invaluable tools in the detection of genetic disorders.

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.

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

Age Group Details

Comparator genome sequence analysis is limited to beneficiaries 21 years of age and younger, Whole genome sequencing requires beneficiary to be 21 years of age or younger.

How to Submit

Please submit your request to EviCore

Resources

Vitamin D, 25 hydroxy D2 and D3, by LC-MS/MS, serum microsample, quantitative

Service Code
0038U (CPT) Vitamin D, 25 hydroxy D2 and D3, by LC-MS/MS, serum microsample, quantitative
Prior Authorization Required
No
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

N/A - No authorization is required