Tests with Medical Necessity Policies

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Test Number
Test Name
CPT® Code(s)
Medicare Coverage
Frequency Applies
3785
LIPID PROFILE
80061
NCD 190.23    A56420
Yes
8730P
HEPATITIS ACUTE PROFILE
80074
NCD 190.33
Yes
1106
DIGOXIN
80162
NCD 190.24
 
3763, 3766, 3762
DRUG SCREEN UA 8 PANEL
80307
   A56645
 
3764
DRUG SCREEN UA 8 WITH ALC
80307
   A56645
 
3698
DRUG SCREEN 9 PANEL
80307
   A56645
 
3699
DRUG SCREEN 10 PANEL PLUS ALCOHOL
80307
   A56645
 
3551
ETHANOL URINE/ ALCOHOL
80307
   A56645
 
8489
Bacterial Vaginosis
81513
87481x2
87661
   A58917


 
 
 
8495
Bacterial Vaginosis Extended Panel
81513
87481x2
87661
87491
87591
87563
   A58917


NCD 210.10
NCD 210.10

 
 
 
 
 
 
2024
ALPHA FETO PROTEIN
82105
NCD 190.25
 
8469
STOOL OCCULT BLOOD GUAIAC
82270
NCD 210.3
Yes
8700
VITAMIN D
82306
   A56416
  Yes
2030
CEA
82378
NCD 190.26
Yes
3050
CHOLESTEROL
82465
NCD 190.23    A56420
Yes
2052
B12
82607
   A56416
 
2160
B12 AND FOLATE
82607/82746
   A56416
 
2036
FERRITIN
82728
NCD 190.18
Yes
4099
ANEMIA PROFILE
82728
82607
82746
83540
83550
85046
85025
NCD 190.18
   A56416
   A56416
NCD 190.18
NCD 190.18

NCD 190.15
Yes
 
 
 
 
 
 
2054
FOLATE
82746
   A56416
 
2026
IGE
82785
   A56558
 
3020
GLUCOSE
82947
NCD 190.20    A56591
Yes
3110
GLUCOSE 1 HR 50 GM
82947
NCD 190.20    A56591
Yes
3112
GLUCOSE 2 HR PP
82947
NCD 190.20    A56591
Yes
3124
GGTP
82977
NCD 190.32
Yes
3010
HEMOGLOBIN A1C
83036
NCD 190.21    A56420
Yes
3126
IRON
83540
NCD 190.18
 
3798
IRON AND TIBC
83540/83550
NCD 190.18
 
3796
IRON, TIBC, % TRANSFERRIN SAT
83540/83550
NCD 190.18
 
3128
IRON BINDING CAPACITY
83550
NCD 190.18
 
3054
HDL
83718
NCD 190.23    A56420
Yes
3057
LDL DIRECT
83721
NCD 190.23    A56420
Yes
2021
PSA DIAGNOSTIC
84153
NCD 190.31
Yes
2023
PSA INDUSTRY
84153
NCD 190.31
Yes
SPLZ926, SPLH926
VITAMIN B6
84207
   A56416
 
3078
T4
84436
NCD 190.22    A56420
Yes
3075
T4 FREE
84439
NCD 190.22    A56420
Yes
2050
TSH
84443
NCD 190.22    A56420
Yes
2050R
TSH W/ REFLEX TO FREE T4
84443
NCD 190.22    A56420
Yes
3052
TRIGLYCERIDES
84478
NCD 190.23    A56420
Yes
3076
T3 UPTAKE
84479
NCD 190.22    A56420
Yes
3824
THYROID PANEL
84479/84436
NCD 190.22    A56420
Yes
2038
HCG QUANT
84702
NCD 190.27
Yes
4230
DIFFERENTIAL
85007
NCD 190.15
 
4024
HEMOGLOBIN
85018
NCD 190.15
 
4215
HEMOGLOBIN AND HCT
85018/85014
NCD 190.15
 
4200
CBC
85025
NCD 190.15
 
4236
WBC ONLY
85048
NCD 190.15
 
7100
PROTIME
85610
NCD 190.17
Yes
7028
PTT
85730
NCD 190.16
 
9100, 9300 AND 9400 SERIES
ALLERGENS (SPECIFIC IGE)
86003
   A56558
 
9415, 9414, 9179
AllERGEN COMPONENTS
86008
   A56558
 
3043
CRP HS
86141
   A56643
 
2020
CA 125
86304
NCD 190.28
 
6028
RPR
86592
NCD 210.10
 
6029
RPR REFLEX
86592
NCD 210.10
 
8620
HEPATITIS B SURFACE AB
86706
NCD 210.6
 
8725P
HEPATITIS EXPOSURE PANEL
86706-2/87340
86704
86803
86701
NCD 210.6
NCD 210.6

NCD 190.14
 
 
 
Yes
8703
SYPHILIS (TREPONEMAL) AB
86780
NCD 210.10
 
SPLH528
HLA B27 ANTIGEN
86812
NCD 190.1
 
8010
URINE CULTURE
87086
87088
NCD 190.12
NCD 190.12
 
 
8520
HEPATITIS B SURFACE AG
87340
NCD 210.6
 
8520
HEPATITIS HBSAG
87340
NCD 210.6
 
8333
CHLAMYDIA AMPLIFIED
87491
NCD 210.10
 
8400
CHLAMY/GC AMPLIFIED
87491/87591
NCD 210.10
 
8458
ENTERIC PARASITE PANEL
87505
   A56642
 
8473
EXTENDED ENTERIC BACTERIAL PANEL
87506
   A56642
 
8335
GC AMPLIFIED
87591
NCD 210.10
 
2022
PSA MC SCREENING
G0103
NCD 210.1
Yes
N/A
PAP Testing
G0123
G0123
G0141
G0143
G0144
G0145
G0147
G0148
P3000
P3001
Q0091
G0476
NCD 210.2
NCD 210.2
NCD 210.2
NCD 210.2
NCD 210.2
NCD 210.2
NCD 210.2
NCD 210.2
NCD 210.2
NCD 210.2
NCD 210.2
NCD 210.2.1    A58216
 
 
 
 
 
 
 
 
 
 
 
 

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11/13/2024 02:53:34 44.210.149.218