Tests with Medical Necessity Policies

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Non-covered ICD-10-CM Codes for All Lab NCDs

Ordering Code
Test Name
CPT® Code(s)
Medicare Coverage
Frequency Applies
5891
6-Acetylmorphine Ur. Scrn Forensic
80307
  A55001
 
5890
6-Acetylmorphine, Ur. Scrn, Clinical
80307
  A55001
 
1801
Acute Hepatitis Panel
80074
NCD 190.33
Yes 80074 - After a hepatitis diagnosis has been established, only individual tests, rather than the entire panel, are needed.
6719
Additional Respiratory Allergen Profile
86003 x7
  A57181
 
6715
Aeroallergen Allergy Panel, IgE
86003 x21
  A57181
 
241
AFP Maternal, Screen - Serum
82105
NCD 190.25
 
106
AFP Non-Maternal - Serum
82105
NCD 190.25
 
4923
Amphetamines, Clinical Urine
80307
  A55001
 
4191
Antidepressants Screen, Urine
80307
  A55001
 
202
Apolipoprotein A1
82172
  A57037
 
203
Apolipoprotein B
82172
  A57037
 
6421
B-Cell Lymph Leukemia Panel, FISH
88271 x6
88275 x3
NCD 190.3   A57661
NCD 190.3   A57661
 
 
7619
B-CELL UNLISTED MOLECULAR PATHOLOGY, TISSUE
81479
A57354
 
4283
B-Natriuretic Peptide
83880
  A57083
 
4924
Barbiturates, Clinical Urine
80307
  A55001
 
5299
BCR-ABL Gene Rearrange, Qnt. Reflex
81206
  A57421   A58454
 
4925
Benzodiazepines, Clinical Urine
80307
  A55001
 
877
Benzodiazepines, Urine Forensic Screen
80307
  A55001
 
7603
BRAF Mutation Analysis
81210
  A54418   A54995
 
7641
BRAF Mutation Analysis
81210
  A54418   A54995
 
7026
BRAF Mutation Analysis
81210
  A54418   A54995
 
5893
Buprenorphine, Urine Screen
80307
  A55001
 
4336
C. Trachomatis PCR, SurePath/ThinPrep
87491
NCD 210.10
 
5147
C. Trachomatis, RNA, TMA, Urogenital
87491
NCD 210.10
 
348
CA 125
86304
NCD 190.28
 
210
CA 19-9
86301
NCD 190.30
 
4659
CA 27.29
86300
NCD 190.29
 
207
CA15-3
86300
NCD 190.29
 
7674
Calreticulin Mutation Analysis
81219
  A57421
 
5143
Cardio IQ (R) LP-PLA2 Activity
83698
  A57037
 
5129
Cardio IQ Advanced Lipid Panel
80061
83704
NCD 190.23
NCD 190.23   A57037
Yes 80061 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL (CPT code 83721) may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.

 
5613
Cardio IQ Lipo Fractionation
83704
NCD 190.23   A57037
 
626C
Cath Urine Culture
87086
NCD 190.12
 
520
CBC w/o Diff
85027
NCD 190.15
 
522
CBC w/Platelet Count
85025
NCD 190.15
 
7177
CD20 + B Cells Profile
86355
86356
  A57689
  A57689
 
 
428
CEA
82378
NCD 190.26
Yes 82378 - Serum CEA determinations are generally not indicated more frequently than once per chemotherapy treatment cycle for patients with metastatic solid tumors which express CEA or every two months post-surgical treatment for patients who have had colorectal carcinoma. It may be proper to order the test more frequently when there has been a significant change from prior CEA level or a significant change in patient status which could reflect disease progression or recurrence. Testing with a diagnosis of an in situ carcinoma is not reasonably done more frequently than once, unless the result is abnormal, in which case the test may be repeated once.
7010
Celiac Disease Genotyping
81376
81383
  A57970
  A57384   A57441
 
 
963
Cell Markers, 1
88184
  A57689
 
976
Cell Markers, 10
88184
88185 x9
88187
  A57689
  A57689
  A57689
 
 
 
977
Cell Markers, 11
88184
88185 x10
88187
  A57689
  A57689
  A57689
 
 
 
979
Cell Markers, 12
88184
88185 x11
88187
  A57689
  A57689
  A57689
 
 
 
981
Cell Markers, 13
88184
88185 x12
88187
  A57689
  A57689
  A57689
 
 
 
982
Cell Markers, 14
88184
88185 x13
88187
  A57689
  A57689
  A57689
 
 
 
983
Cell Markers, 15
88184
88185 x14
88187
  A57689
  A57689
  A57689
 
 
 
985
Cell Markers, 16
88184
88185 x15
88187
  A57689
  A57689
  A57689
 
 
 
989
Cell Markers, 17
88184
88185 x16
88187
  A57689
  A57689
  A57689
 
 
 
990
Cell Markers, 18
88184
88185 x17
88187
  A57689
  A57689
  A57689
 
 
 
4910
Cell Markers, 19
88184
88185 x18
88187
  A57689
  A57689
  A57689
 
 
 
4539
Cell Markers, 2
88184
88185
88187
  A57689
  A57689
  A57689
 
 
 
4911
Cell Markers, 20
88184
88185 x19
88187
  A57689
  A57689
  A57689
 
 
 
4912
Cell Markers, 21
88184
88185 x20
88187
  A57689
  A57689
  A57689
 
 
 
4913
Cell Markers, 22
88184
88185 x21
88187
  A57689
  A57689
  A57689
 
 
 
5663
Cell Markers, 23
88184
88185 x22
88187
  A57689
  A57689
  A57689
 
 
 
5664
Cell Markers, 24
88184
88185 x23
88187
  A57689
  A57689
  A57689
 
 
 
5665
Cell Markers, 25
88184
88185 x24
88187
  A57689
  A57689
  A57689
 
 
 
5666
Cell Markers, 26
88184
88185 x25
88187
  A57689
  A57689
  A57689
 
 
 
5667
Cell Markers, 27
88184
88185 x26
88187
  A57689
  A57689
  A57689
 
 
 
6557
Cell Markers, 28
88184
88185 x27
88187
  A57689
  A57689
  A57689
 
 
 
6558
Cell Markers, 29
88184
88185 x28
88187
  A57689
  A57689
  A57689
 
 
 
4540
Cell Markers, 3
88184
88185 x2
88187
  A57689
  A57689
  A57689
 
 
 
6559
Cell Markers, 30
88184
88185 x29
88187
  A57689
  A57689
  A57689
 
 
 
6560
Cell Markers, 31
88184
88185 x30
88187
  A57689
  A57689
  A57689
 
 
 
6561
Cell Markers, 32
88184
88185 x31
88187
  A57689
  A57689
  A57689
 
 
 
955
Cell Markers, 4
88184
88185 x3
88187
  A57689
  A57689
  A57689
 
 
 
967
Cell Markers, 5
88184
88185 x4
88187
  A57689
  A57689
  A57689
 
 
 
968
Cell Markers, 6
88184
88185 x5
88187
  A57689
  A57689
  A57689
 
 
 
986
Cell Markers, 7
88184
88185 x6
88187
  A57689
  A57689
  A57689
 
 
 
974
Cell Markers, 8
88184
88185 x7
88187
  A57689
  A57689
  A57689
 
 
 
975
Cell Markers, 9
88184
88185 x8
88187
  A57689
  A57689
  A57689
 
 
 
5324
Chlamydia & Chlamydophila Ab Panel
86631 x6
88632 x3
NCD 210.10

 
 
5324
Chlamydia & Chlamydophila Ab Panel
86631
NCD 210.10
 
4960
Chlamydia & Chlamydophila Ab, IgG
86631
NCD 210.10
 
4960
Chlamydia & Chlamydophila Ab, IgG
86631
NCD 210.10
 
4961
Chlamydia & Chlamydophila Ab, IgM
86632
NCD 210.10
 
5842
Chlamydia / GC TMA, Rectal
87491
NCD 210.10
 
7162
Chlamydia / GC TMA, Throat
87491
NCD 210.10
 
4328
Chlamydia and GC, PCR
87591
NCD 210.10
 
484
Chlamydia Trachomatis PCR
87491
NCD 210.10
 
5848
Chlamydia Trachomatis TMA, Rectal
87491
NCD 210.10
 
5846
Chlamydia Trachomatis TMA, Throat
87491
NCD 210.10
 
4183
Chlamydia Trachomatis, Culture
87110
NCD 210.10
 
4336
Chlamydia Trachomatis, PCR
87491
NCD 210.10
 
484
Chlamydia, PCR
87491
NCD 210.10
 
183
Chlamydia/GC PCR, Urine or Genital
87591
NCD 210.10
 
183
Chlamydia/GC, PCR
87491
NCD 210.10
 
4328
Chlamydia/GC, PCR, SurePath/ThinPrep
87491
NCD 210.10
 
142
Cholesterol
82465
NCD 190.23
Yes 82465 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL (CPT code 83721) may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.
6736
Chromogranin A
86316
  A55028
 
86
Chromosome Analysis Amniotic Fluid
88235
88269
88280
88285
NCD 190.3
NCD 190.3
NCD 190.3
NCD 190.3
 
 
 
 
267
Chromosome Analysis, Blood
88230
88262
NCD 190.3
NCD 190.3
 
 
6648
Chromosome Analysis, Leukemic Blood
88237
88264
NCD 190.3
NCD 190.3
 
 
87
Chromosome Analysis, POC
88233
88262
NCD 190.3
NCD 190.3
 
 
4734
Clinical Substance Abuse Panel 10
80307
  A55001
 
4735
Clinical Substance Abuse Panel 10A
80307
  A55001
 
5575
Clinical Substance Abuse Panel 11 E
80307
  A55001
 
4736
Clinical Substance Abuse Panel 11A
80307
  A55001
 
4731
Clinical Substance Abuse Panel 5
80307
  A55001
 
885
Clinical Substance Abuse Panel 5A
80307
  A55001
 
4732
Clinical Substance Abuse Panel 7
80307
  A55001
 
5868
Clinical Substance Abuse Panel 8 Ox
80307
  A55001
 
725
Clinical Substance Abuse Panel 8A
80307
  A55001
 
4733
Clinical Substance Abuse Panel 9A
80307
  A55001
 
4915
Cocaine / Amphetamine Urine Screen
80307
  A55001
 
4926
Cocaine Metabolite
80307
  A55001
 
4391
Coenzyme Q10
82542
  A55769
 
4367
Collagen Cross-Linked, NTX, 24 Hr Urine
82523
NCD 190.19
Yes 82523 - Current recommendations for appropriate utilization include: one or two base-line assays from specified urine collections on separate days; followed by a repeat assay about three months after starting anti-resorptive therapy; followed by a repeat assay in 12 months after the three-month assay; and thereafter not more than annually, unless there is a change in therapy in which circumstance an additional test may be indicated three months after the initiation of new therapy.
4978
Collagen Cross-Linked, NTX, Random Urine
82523
NCD 190.19
Yes 82523 - Current recommendations for appropriate utilization include: one or two base-line assays from specified urine collections on separate days; followed by a repeat assay about three months after starting anti-resorptive therapy; followed by a repeat assay in 12 months after the three-month assay; and thereafter not more than annually, unless there is a change in therapy in which circumstance an additional test may be indicated three months after the initiation of new therapy.
5553
Collagen Type I C-Telopeptide
82523
NCD 190.19
Yes 82523 - Current recommendations for appropriate utilization include: one or two base-line assays from specified urine collections on separate days; followed by a repeat assay about three months after starting anti-resorptive therapy; followed by a repeat assay in 12 months after the three-month assay; and thereafter not more than annually, unless there is a change in therapy in which circumstance an additional test may be indicated three months after the initiation of new therapy.
N/A
Colorectal Cancer Screening Tests
82272
NCD 190.34
 
N/A
Colorectal Cancer Screening Tests
G0328
NCD 210.3
 
7120
Comprehensive Drug Screen, Serum
80307
  A55001
 
4784
Comprehensive Urine Drug Screen
80307
  A55001
 
5461
CRP (High Sensitivity)
86141
  A57037
 
5127
CT / NG RNA, TMA, Urogenital
87491
NCD 210.10
 
626
Culture, Urine
87086
NCD 190.12
 
5843
CYP2C19
81225
  A57384
 
6422
Cystatin C
82610
  A57037   A57643
 
5122
Cystatin C with GFR, Estimated
82610
  A57037   A57643
 
5149
Cystic Fibrosis, Carrier Screen
81220
  A57384
 
N/A
Cytopath, Pap Smear (Neopath & Manual Rescreen)
G0148
NCD 210.2
 
N/A
Cytopath, Pap Smear (Neopath Only)
G0147
NCD 210.2
 
6738
Cytopath, Thin Prep & Manual Screen
G0123
NCD 210.2
 
437
Digoxin
80162
NCD 190.24
 
811M
Drug Screen # 4 (Medical)
80307
  A55001
 
471
Drugs of Abuse Screen (7 Panel), Meconium
80307
  A55001
 
6700
Dust / Mite Allergen Panel, IgE
86003 x4
  A57181
 
5778
Electrolyte & Osmolality Panel, Fecal
83735
  A57189
 
530
Eosinophil Count, Total
85048
NCD 190.15
 
6701
Epithelia Allergen Panel, IgE
86003 x6
  A57181
 
4605
Ethanol, Clinical Urine
80307
  A55001
 
879
Ethanol, Urine Forensic Screen
80307
  A55001
 
7710
Ethyl Glucuronide, Random Urine
80307
  A55001
 
7220
Ethyl Glucuronide, Urine Screen
80307
  A55001
 
4567
Factor V Leiden Mutation Analysis
81241
  A57423
 
415
Ferritin
82728
NCD 190.18
Yes 82728 - If a normal serum ferritin level is documented, repeat testing would not ordinarily be medically necessary unless there is a change in the patient's condition, and ferritin assessment is needed for the ongoing management of the patient. When an End Stage Renal Disease (ESRD) patient is tested for ferritin, testing more frequently than every three months (the frequency authorized by 3167.3, Fiscal Intermediary manual) requires documentation of medical necessity [e.g., other than Chronic Renal Failure (ICD-9-CM 585) or Renal Failure, Unspecified (ICD-9-CM 586)].
6705
Fish Allergen Panel, IgE
86003 x7
  A57181
 
6724
Food Allergy Panel
86003 x15
  A57181
 
6716
Food Allergy Profile (Phadia)
86003 x12
  A57181
 
4127
Fragile X Carrier Screen - PCR
81243
  A55241
 
4126
Fragile X Test (Symptomatic/Family)
81243
81244
  A55241
  A55241
 
 
5986
Free PSA with Total PSA
84153
NCD 190.31
Yes 84153 - For patients with lower urinary tract signs or symptoms, total PSA is performed only once per year unless there is a change in the patient's medical condirtion. Medicare covers a screening total PSA test one each year for men over 50 years of age.
4700
Fructosamine
82985
NCD 190.21
 
6708
Fruit Allergen Panel, IgE
86003 x6
  A57181
 
226
FTA-ABS
86780
NCD 210.10
 
226
FTA-ABS
86780
NCD 210.10
 
172
Gamma GT
82977
NCD 190.32
Yes 82977 - When used to determine if other abnormal enzyme tests reflect liver abnormality rather than other tissue, it generally is not necessary to repeat a GGT more than one time per week.
479
GC, PCR
87591
NCD 210.10
 
4008
GC/MS NIDA Lab
80307
  A55001
 
176
Glucose
82947
NCD 190.20
Yes 82947 - In stable, non-hospitalized patients who are unable or unwilling to do home glucose monitoring, it may be reasonable and necessary to measure quantitative blood glucose up to 4 times annually. Depending on the age and condition of the patient, the type of diabetes, degree of control, and other co-morbid conditions, more frequent testing may be reasonable and necessary.
6612
Glycomark (R)
84378
  A57237
 
6707
Grain Allergen Panel, IgE
86003 x6
  A57181
 
6702
Grass Allergen Panel, IgE
86003 x8
  A57181
 
6723
Hawaii Regional Respiratory Allergy Panel
86003 x25
  A57181
 
6718
Hawaii Regional Respiratory Allergy Profile (Phadia)
86003 x17
  A57181
 
468P
HCG, Quant Pregnancy
84702
NCD 190.27
Yes 84702 - Not more than once per month for diagnostic purposes. As needed for monitoring of patient progress and treatment. Qualitative hCG assays (CPT 84703) are not appropriate for medically managing patients with known or suspected germ cell neoplasms.
468T
HCG, Quant, Tumor
84702
NCD 190.27
Yes 84702 - Not more than once per month for diagnostic purposes. As needed for monitoring of patient progress and treatment. Qualitative hCG assays (CPT 84703) are not appropriate for medically managing patients with known or suspected germ cell neoplasms.
189
HDL - Cholesterol
83718
NCD 190.23
Yes 83718 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL (CPT code 83721) may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.
4182
HDL Cholesterol Subclasses
83701
NCD 190.23   A57037
 
536
Hematocrit
85014
NCD 190.15
 
538
Hemoglobin
85018
NCD 190.15
 
537
Hemoglobin & Hematocrit
85014
85018
NCD 190.15
NCD 190.15
 
 
4779
Hemoglobin A1C
83036
NCD 190.21
Yes 83036 - It is not considered reasonable and necessary to perform glycated hemoglobin tests more often than every three months on a controlled diabetic patient to determine whether the patient's metabolic control has been on average within the target range. It is not considered reasonable and necessary for these tests to be performed more frequently than once a month for diabetic pregnant women. Testing for uncontrolled type one or two diabetes mellitus may require testing more than four times a year. Medical necessity documentation must support such testing in excess of the above guidelines.
499
Hepatitis B Core Antibody, Total
86704
NCD 210.6
 
501
Hepatitis B Surface Ag, Confirmation
87341
NCD 210.6
 
500
Hepatitis B Surface Antibody
86706
NCD 210.6
 
495
Hepatitis B Surface Antigen
87340
NCD 210.6
 
5691
Hepatitis BsAg w/Reflex to Confirmation
87340
NCD 210.6
 
542
Hepatitis C Antibody
G0472
NCD 210.13
 
5275
HIV-1 DNA, Qualitative, PCR
87535
NCD 190.14
Yes 87535 - If initial serologic tests are HIV EIA negative and there is no indication for confirmation of infection by viral RNA detection, the interval prior to retesting is 3-6 months.
4609
HIV-1 RNA, Quant
87536
NCD 190.13
Yes 87536 - Measurement of plasma HIV RNA levels should be performed at the time of establishment of an HIV infection diagnosis. For an accurate baseline, 2 specimens in a 2-week period are appropriate.
5688
HIV-1/2 Ag / Ab with Reflex
G0432
NCD 210.7
 
7139
HLA A,B Typing (Platelet Refractory)
86813
NCD 190.1
 
7140
HLA-A,B,C,DR,DQ Typing (TRALI)
81370
  A57970
 
7136
HLA-A,B,C,DR,DQ, Renal
81370
  A57970
 
7137
HLA-A,B,C,DR,DQA,DQB,DP Deceased
81370
81376
  A57970
  A57970
 
 
5808
HLA-B*5701 Typing
81381
  A57384
 
458
HLA-B27
86812
NCD 190.1
 
7148
HLA-C
81373
  A57970
 
7151
HLA-DQB
81376
  A57970
 
4686
Homocysteine, Total Serum
83090
  A57037
 
5088
HTLV I/II Ab, Western Blot
86689
NCD 190.14
Yes 86689 - If initial serologic tests are HIV EIA negative and there is no indication for confirmation of infection by viral RNA detection, the interval prior to retesting is 3-6 months.
5892
Hydrocodone, Ur. Scrn, Clinical
80307
  A55001
 
1ID
ID, Organism, Urine 1
87088
NCD 190.12
 
2ID
ID, Organism, Urine 2
87088
NCD 190.12
 
3ID
ID, Organism, Urine 3
87088
NCD 190.12
 
4ID
ID, Organism, Urine 4
87088
NCD 190.12
 
5ID
ID, Organism, Urine 5
87088
NCD 190.12
 
6ID
ID, Organism, Urine 6
87088
NCD 190.12
 
5078
IHC Morphometry
88361
  A57611
 
7169
Immunodeficieny Panel 1 Profile
86355
86359
86360
  A57689
  A57689
  A57689
 
 
 
7170
Immunodeficieny Panel 2 Profile
86355
86357
86359
86360
  A57689
  A57689
  A57689
  A57689
 
 
 
 
6725
Infant Allergen Panel, IgE
86003 x16
  A57181
 
276
Iron Binding Capacity
83540
83550
NCD 190.18
NCD 190.18
 
 
287
Iron, Total
83540
NCD 190.18
 
6614
JAK2 Exon 12 Mutation Analysis
81403
  A54995
 
5047
JAK2 V617F Mutation Analysis
81270
  A57421
 
6613
JAK2, V617F Mutation, Qual w/ Reflex Exon 12
81270
  A57421
 
5449
LDL-Cholesterol, Direct
83721
NCD 190.23   A57037
Yes 83721 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL (CPT code 83721) may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.
6709
Legumes/Nuts Allergen Panel, IgE
86003 x7
  A57181
 
5181
LGV Differential Antibody Panel
86631
NCD 210.10
 
5181
LGV Differential Antibody Panel
86631 x8
86632 x4
NCD 210.10
NCD 210.10
 
 
915
Lipid Panel
80061
NCD 190.23
Yes 80061 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL (CPT code 83721) may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.
231
Lipoprotein A
83695
  A57037
 
409
Lipoprotein ELP (Phenotype)
82465
83700
84478
NCD 190.23
NCD 190.23   A57037
NCD 190.23
Yes 82465 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL (CPT code 83721) may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.

 
Yes 84478 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.

410
Lipoprotein Metabolism Profile
80061
82172
83700
NCD 190.23
  A57037
NCD 190.23   A57037
Yes 80061 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL (CPT code 83721) may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.

 
 
5295
Liver Fibrosis, Fibrotest
82172
  A57037
 
5144
LP-PLA2 Activity
83698
  A57037
 
7659
Lung NGS Fusion Profile
81445
  A55624   A57901   A58454
 
200
Magnesium
83735
  A57189
 
7183
Magnesium, RBC
83735
  A57189
 
531
Magnesium, Urine
83735
  A57189
 
6737
MDMA (Ecstacy), Urine Screen
80307
  A55001
 
6704
Meat Allergen Panel, IgE
86003 x5
  A57181
 
4716
Meconium (Mec Stat-5)
80307
  A55001
 
4927
Methadone, Clinical Urine
80307
  A55001
 
6703
Molds Allergen Panel, IgE
86003 x13
  A57181
 
6185
MTHFR Mutation Analysis
81291
  A57423
 
5276
N-Telopeptide
82523
NCD 190.19
Yes 82523 - Current recommendations for appropriate utilization include: one or two base-line assays from specified urine collections on separate days; followed by a repeat assay about three months after starting anti-resorptive therapy; followed by a repeat assay in 12 months after the three-month assay; and thereafter not more than annually, unless there is a change in therapy in which circumstance an additional test may be indicated three months after the initiation of new therapy.
4337
N. Gonorrhoeae PCR, SurePath/ThinPrep
87591
NCD 210.10
 
7178
Natural Killer Cells Profile
86357
  A57689
 
479
Neisseria Gonorrhoeae PCR
87591
NCD 210.10
 
5849
Neisseria Gonorrhoeae TMA, Rectal
87591
NCD 210.10
 
5847
Neisseria Gonorrhoeae TMA, Throat
87591
NCD 210.10
 
4337
Neisseria Gonorrhoeae, PCR
87591
NCD 210.10
 
5898
Neisseria Gonorrhoeae, TMA, Urogenital
87591
NCD 210.10
 
5298
Neuron Specific Enolase (CSF)
86316
  A55028
 
7613
NGS Oncology Melanoma Profile
81445
88381
  A57901   A58454

 
 
7207
NGS Oncology Melanoma Profile (Tissue Only)
81445
  A55624   A57901   A58454
 
7206
NGS Oncology Tumor Profile (Tissue Only)
81445
  A54995   A58454
 
7612
NGS Target Oncology Mutation Panel
81445
  A55624   A57901   A58454
 
4551
NIDA 5, GC/MS
80307
  A55001
 
7625
Novel Psychoactive Sub. Screen, Urine
80307
  A55001
 
7621
NPS Screen 1, Blood
80307
  A55001
 
7622
NPS Screen 2, Blood
80307
  A55001
 
7662
NRAS Mutation Analysis
81403
81311

  A57486
 
 
5774
NT proBNP
83880
  A57083
 
7028
NTRK NGS Fusion Profile
81479
A55624 A57354 A57901
 
4928
Opiates, Clinical Urine
80307
  A55001
 
6711
Other Food Allergen Panel, IgE
86003 x6
  A57181
 
6423
Oxycodone, Clinical Urine
80307
  A55001
 
4572
P, Spcl Stain Pas
88313
  A55802
 
4839
P, Stain,Acid Fast
88312
  A55802
 
4869
P, Stain,Group 1
88312
  A55802
 
4870
P, Stain,Group 2
88313
  A55802
 
4880
P, Stain,Mast Cells X3
88313 x3
  A55802
 
7029
Pan-TRK
88342
  A55802
 
4025
Pap in Fld (Neopath - Manual Rescreen)
G0145
NCD 210.2
 
4024
Pap in Fld (Neopath Only)
G0144
NCD 210.2
 
7631
Pap Smear w/ Reflex to HPV
G0476
NCD 210.2.1
 
516
Part. Throm. Time (PTT)
85730
NCD 190.16
 
6714
Perennial Allergen Panel, IgE
86003 x18
  A57181
 
4929
Phencyclidine, Clinical Urine
80307
  A55001
 
576
Platelet Aggregation
85049
85576 x5
NCD 190.15

 
 
546
Platelet Count
85049
NCD 190.15
 
5554
Platelet Morphology
85008
NCD 190.15
 
7212
Pneumonia Panel by Filmarray
87632
  A57338
 
4930
Propoxyphene, Clinical Urine
80307
  A55001
 
5823
Prostatitis Culture
87086
NCD 190.12
 
5428
Prothrombin G20210A Mutation (Factor II)
81240
  A57423
 
514
Prothrombin Time (PT)
85610
NCD 190.17
Yes 85610 - When an ESRD patient is tested for PT, testing more frequently than weekly requires documentation of medical necessity [e.g. other than Chronic Renal Failure (ICD-9-CM 585) or Renal Failure, Unspecified (ICD-9-CM 586)]. The need to repeat this test is determined by changes in the underlying medical condition and/or the dosing of warfarin. In a patient on stable warfarin therapy, it is ordinarily not necessary to repeat testing more than every two to three weeks.
505
PSA, Total
84153
NCD 190.31
Yes 84153 - For patients with lower urinary tract signs or symptoms, total PSA is performed only once per year unless there is a change in the patient's medical condirtion. Medicare covers a screening total PSA test one each year for men over 50 years of age.
6439
Respiratory Panel by Filmarray
87633
  A57338
 
7034
ROS1
88342
  A54995
 
695R
RPR, Reflex to Titer
86592
NCD 210.10
 
7189
SAP 10 GC/MS, Ref
80307
  A55001
 
7188
SAP 4 GC/MS, Ref
80307
  A55001
 
6706
Shellfish Allergen Panel, IgE
86003 x6
  A57181
 
6188
Stonerisk Diagnostic Profile
83735
  A57189
 
5600
Stool GI Pathogen Panel, PCR
87507
  A56706
 
7194
Synthetic Cannabinoid Metab., Urine
80307
  A55001
 
7620
Synthetic Cannabinoids Screen, Blood
80307
  A55001
 
7172
T Cell Subset Panel (T4/T8 Ratio)
86359
86360
  A57689
  A57689
 
 
971
T Helper-Inducer (CD4)
86359
86361
  A57689
  A57689
 
 
5174
T3 Uptake
84479
NCD 190.22
Yes 84479 - Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyper- or hypothyroidism are noted.
366
T4, Free
84439
NCD 190.22
Yes 84439 - Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyper- or hypothyroidism are noted.
4710
T4, Free (Direct Dialysis)
84439
NCD 190.22
Yes 84439 - Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyper- or hypothyroidism are noted.
5531
T4, Total
84436
NCD 190.22
Yes 84436 - Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyper- or hypothyroidism are noted.
4931
THC, Clinical Urine
80307
  A55001
 
4875
Tissue - Stain, Immunoperoxidase
88342
  A55802
 
7176
Total B Cells Profile
86355
  A57689
 
6426
Tox - Clinical SAP 10 OA
80307
  A55001
 
6734
Tox - Clinical SAP 10 XO
80307
  A55001
 
6427
Tox - Clinical SAP 11 OA
80307
  A55001
 
6424
Tox - Clinical SAP 6 OA
80307
  A55001
 
6425
Tox - Clinical SAP 8 OA
80307
  A55001
 
4729
Tox - SAP 10
80307
  A55001
 
4737
Tox - SAP 10, GC/MS
80307
  A55001
 
5544
Tox - SAP 11 X
80307
  A55001
 
4730
Tox - SAP 11A
80307
  A55001
 
4727
Tox - SAP 11A, GC/MS
80307
  A55001
 
5484
Tox - SAP 4 w/o THC, GC/MS
80307
  A55001
 
4742
Tox - SAP 4, GC/MS
80307
  A55001
 
6638
Tox - SAP 5 D, GC/MS
80307
  A55001
 
5171
Tox - SAP 5 LP, GC/MS
80307
  A55001
 
4728
Tox - SAP 5, GC/MS
80307
  A55001
 
5469
Tox - SAP 5, GC/MS POC
80307
  A55001
 
5674
Tox - SAP 5, GC/MS-DISC
80307
  A55001
 
5476
Tox - SAP 5, POC
80307
  A55001
 
355
Tox - SAP 5A
80307
  A55001
 
4738
Tox - SAP 5A, GC/MS
80307
  A55001
 
4178
Tox - SAP 6 BO
80307
  A55001
 
4682
Tox - SAP 6 NG
80307
  A55001
 
5543
Tox - SAP 6 X
80307
  A55001
 
4739
Tox - SAP 6, GC/MS
80307
  A55001
 
5984
Tox - SAP 6Ab, Intake
80307
  A55001
 
809
Tox - SAP 7
80307
  A55001
 
4179
Tox - SAP 7 ABO
80307
  A55001
 
4740
Tox - SAP 7, GC/MS
80307
  A55001
 
4741
Tox - SAP 7A, GC/MS
80307
  A55001
 
7221
Tox - SAP 7A, Intake
80307
  A55001
 
285
Tox - SAP 7AB
80307
  A55001
 
6191
Tox - SAP 9, GC/MS
80307
  A55001
 
4726
Tox - SAP 9A, GC/MS
80307
  A55001
 
6629
TPMT Genotype
81335
  A57384
 
434
Transferrin
84466
NCD 190.18
 
4292
Treponema Pallidum Ab CSF
86780
NCD 210.10
 
4292
Treponema Pallidum Ab CSF
86780
NCD 210.10
 
228
Triglycerides
84478
NCD 190.23
Yes 84478 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.
380
TSH
84443
NCD 190.22
Yes 84443 - Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyper- or hypothyroidism are noted.
449
TSH / T4, Free
84439
84443
NCD 190.22
NCD 190.22
Yes 84439 - Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyper- or hypothyroidism are noted.

Yes 84443 - Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyper- or hypothyroidism are noted.

810M
Urine Drug Screen, #2 (Medical)
80307
  A55001
 
820
Urine Drug Screen, #2 (Medical)
80307
  A55001
 
6177
Urorisk Diagnostic Profile
83735
  A57189
 
59R
VDRL, CSF Reflex to Titer
86592
NCD 210.10
 
6710
Vegetable Allergen Panel, IgE
86003 x14
  A57181
 
6712
Venom Allergen Panel, IgE
86003 x5
  A57181
 
4990
Vitamin D (1,25 Dihydroxy)
82652
  A57718
 
5679
Vitamin D, 25-Hydroxy (D2 & D3)
82306
  A57718
 
Yes For frequency limitations, please review the "Indications and Limitations of Coverage" section within the Article and any associated LCD Policies indicated.
6556
Vitamin D, 25-Hydroxy, Total
82306
  A57718
 
Yes For frequency limitations, please review the "Indications and Limitations of Coverage" section within the Article and any associated LCD Policies indicated.
564
White Blood Count
85048
NCD 190.15
 
6205
ZAP70
88184
88185
88187
  A57689
  A57689
  A57689