About this policy
Jurisdiction: J6 MAC Part B. States: Illinois, Minnesota, Wisconsin. Type: Active LCD
Coverage indications
Acute Myelogenous Leukemia (AML) Indications Genomic Sequential Analysis Panel will be considered reasonable and necessary in the evaluation of blood or bone marrow samples in the following clinical circumstances: Genomic Sequential Analysis Panel will be considered reasonable and necessary in the evaluation of blood or bone marrow samples for newly diagnosed or relapsed/refractory AML patients who are candidates for treatment, regardless of karyotype findings. Previously diagnosed patients with AML, who have not responded to induction chemotherapy, or who have progressed following induction. The patient must be a candidate for transplantation at the time of the testing. Patients with AML, who have responded to treatment, either chemotherapy or transplantation, with evidence of relapse. Myelodysplastic Syndromes (MDS) Indications Genomic Sequential Analysis Panel will be considered reasonable and necessary in the evaluation of blood or bone marrow samples in the following clinical circumstances: Patients with clinical signs or symptoms of myelodysplastic syndromes (MDS) or myelodysplastic/myeloproliferative overlap syndromes (MDS/MPN), in whom clinical, laboratory, and pathologic assessment are nondiagnostic. Newly diagnosed MDS or MDS/MPN patients either stratified by the IPSS or IPSS-R as intermediate risk, or in MDS with ringed sideroblasts/RARS. Repeat Genomic Sequential Analysis Panel testing is considered reasonable and necessary in MDS after initial diagnosis and risk stratification. Myeloproliferative Neoplasms (MPN) Indications and Limitations of Coverage Genomic Sequential Analysis Panel will be considered reasonable and necessary in the evaluation of blood or bone marrow samples in the following circumstances: Diagnosis: Clinical signs or symptoms of myeloproliferative neoplasm (MPN) or myelodysplastic/myeloproliferative overlap syndromes (MDS/MPN) when clinical, laboratory, and pathologic assessment are nondiagnostic; and CML excluded (BCR-ABL1 negative) 1,2 Risk Stratification: Newly diagnosed PMF not already classified as high-risk by Dynamic International Prognostic Scoring System (DIPSS) Plus 1,3,4 Monitoring: Higher-risk MF (INT-1, INT-2, High-Risk) with progression on therapy 1
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 81450 | CPT | Covered |
| 81451 | CPT | Covered |
| 81455 | CPT | Covered |
| 81456 | CPT | Covered |
| C88.80 | ICD10CM | Covered |
| C92.00 | ICD10CM | Covered |
| C92.02 | ICD10CM | Covered |
| C92.10 | ICD10CM | Covered |
| C92.12 | ICD10CM | Covered |
| C92.20 | ICD10CM | Covered |
| C92.22 | ICD10CM | Covered |
| C92.30 | ICD10CM | Covered |