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CPT Code | Description | Effective
date | Termination
date | Line of Business
(HIP and GHI NonCity membership) | Does Diagnosis Code
Rule Apply? | Diagnosis Code Rule
REQUIRES PA
for the following diagnosis codes: | Diagnosis Code Rule
Does NOT require a PA
for the following diagnosis codes: | *Site of Service (SOS) Preauthorization REQUIRED for Following Sites of Service ONLY: 19 & 22
*Members Under 75 years of Age
(75 years of age and older - SOS does Not Apply) | Notes , Comments | General category |
---|
CPT Code | Description | Effective
date | Termination
date | Line of Business
(HIP and GHI NonCity membership) | Does Diagnosis Code
Rule Apply? | Diagnosis Code Rule
REQUIRES PA
for the following diagnosis codes: | Diagnosis Code Rule
Does NOT require a PA
for the following diagnosis codes: | *Site of Service (SOS) Preauthorization REQUIRED for Following Sites of Service ONLY: 19 & 22
*Members Under 75 years of Age
(75 years of age and older - SOS does Not Apply) | Notes , Comments | General category |
---|---|---|---|---|---|---|---|---|---|---|
0012M | 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 urothelial carcinoma | 01/15/2023 | HIP Commercial, HIP Medicare, GHI EPO/PPO, GHI Medicare | N/A | Prior Authorization required for all Diagnosis Codes | N/A | New PA Requirement | Preauthorization - EH services | ||
0013M | 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 | 01/15/2023 | HIP Commercial, HIP Medicare, GHI EPO/PPO, GHI Medicare | N/A | Prior Authorization required for all Diagnosis Codes | N/A | New PA Requirement | Preauthorization - EH services | ||
0017M | 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 | 01/15/2023 | HIP Commercial, HIP Medicare, GHI EPO/PPO, GHI Medicare | N/A | Prior Authorization required for all Diagnosis Codes | N/A | New PA Requirement | Preauthorization - EH services | ||
0037U | 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 | 06/15/2024 | HIP Commercial, HIP Medicare, GHI EPO/PPO, GHI Medicare | N/A | Prior Authorization required for all Diagnosis Codes | N/A | N/A | New PA Requirement | Preauthorization - EH services | |
0228U | Oncology (prostate), multianalyte molecular profile by photometric detection of macromolecules adsorbed on nanosponge array slides with machine learning, utilizing first morning voided urine, algorithm reported as likelihood of prostate cancer | 01/01/2021 | HIP Commercial, HIP Medicare, HIP Medicaid, GHI EPO/PPO, GHI Medicare | N/A | Prior Authorization required for all Diagnosis Codes | N/A | N/A | Preauthorization - EH services | ||
0229U | BCAT1 (Branched chain amino acid transaminase 1) or IKZF1 (IKAROS family zinc finger 1) (eg, colorectal cancer) promoter methylation analysis | 01/01/2021 | HIP Commercial, HIP Medicare, HIP Medicaid, GHI EPO/PPO, GHI Medicare | N/A | Prior Authorization required for all Diagnosis Codes | N/A | N/A | Preauthorization - EH services | ||
0230U | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation), full sequence analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions | 01/01/2021 | HIP Commercial, HIP Medicare, HIP Medicaid, GHI EPO/PPO, GHI Medicare | N/A | Prior Authorization required for all Diagnosis Codes | N/A | N/A | Preauthorization - EH services | ||
0231U | CACNA1A (calcium voltage-gated channel subunit alpha 1A) (eg, spinocerebellar ataxia), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) gene expansions, mobile element insertions, and variants in non-uniquely mappable regions | 01/01/2021 | HIP Commercial, HIP Medicare, HIP Medicaid, GHI EPO/PPO, GHI Medicare | N/A | Prior Authorization required for all Diagnosis Codes | N/A | N/A | Preauthorization - EH services | ||
0232U | CSTB (cystatin B) (eg, progressive myoclonic epilepsy type 1A, Unverricht-Lundborg disease), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions | 01/01/2021 | HIP Commercial, HIP Medicare, HIP Medicaid, GHI EPO/PPO, GHI Medicare | N/A | Prior Authorization required for all Diagnosis Codes | N/A | N/A | Preauthorization - EH services | ||
0233U | FXN (frataxin) (eg, Friedreich ataxia), gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions | 01/01/2021 | HIP Commercial, HIP Medicare, HIP Medicaid, GHI EPO/PPO, GHI Medicare | N/A | Prior Authorization required for all Diagnosis Codes | N/A | N/A | Preauthorization - EH services |