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
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
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
