Covered without prior authorization (high confidence)
Documentation Required
Reimbursement will only be provided if a requested service(s) is submitted in accordance with the relevant criteria outlined in the applicable Coverage Policy, including covered diagnosis and/or procedure code(s).
Claims submitted for services that are not accompanied by covered code(s) under the applicable Coverage Policy will be denied as not covered.
When billing, providers must use the most appropriate codes as of the effective date of the submission.
Each coverage request should be reviewed on its own merits; medical directors may exercise clinical judgment and determinations require consideration of the terms of the applicable benefit plan, applicable laws/regulations, relevant collateral source materials including Coverage Policies, and the specific facts of the situation.
Key Coverage Criteria
Flow cytometry is considered medically necessary for the evaluation of any of the following: Hematopoietic/hematologic cancers; Immunodeficiency disorders, including human immunodeficiency virus (HIV) and acquired immunodeficiency virus syndrome (AIDS); Paroxysmal nocturnal hemoglobinuria; Gestational trophoblastic disease; Transplantation.
Diagnosis and/or evaluation of hematopoietic cancers, including lymphomas and leukemia, plasma cell neoplasms, myelodysplastic syndromes, myeloproliferative neoplasms, and certain anemias (as described in General Background).
Monitoring lymphocyte populations (e.g., T-cells, NK cells), including CD4 and CD8 counts and CD4/CD8 ratio for management of HIV disease (eligibility for antiretroviral therapy, monitoring immune restoration, guiding treatment against opportunistic infections).
Detection of minimal residual disease and detection of antigens used as therapeutic drug targets for cancer therapy (hematologic malignancies).
Diagnosis of paroxysmal nocturnal hemoglobinuria (PNH) — flow cytometry is considered the gold standard for identifying peripheral blood cells missing GPI-anchored proteins.
Assessment of DNA ploidy in gestational trophoblastic disease, including molar pregnancies.