About this policy
Jurisdiction: JK MAC Part B. States: Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont. Type: Active LCD
Coverage indications
Indications of Coverage The use of serum mass spectrometry (MS) in monoclonal gammopathies (MGs), and the concurrent use of serum or urine immunofixation electrophoresis (sIFE) is considered medically necessary for: Diagnosis: Initial detection of M-protein in patients with suspected monoclonal gammopathy (MG) to confirm a serum protein electrophoresis (SPEP) or serum free light-chain (sFLC) abnormality (1), or Monitoring: Discrimination between therapeutic monoclonal antibodies and endogenous M-proteins (2), or Treatment response assessment per guidelines (3-5) Limitations of Coverage (not covered) Screening
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 |
|---|---|---|
| 0077U | HCPCS | Covered |
| C83.00 | ICD10CM | Covered |
| C88.00 | ICD10CM | Covered |
| C88.20 | ICD10CM | Covered |
| C90.00 | ICD10CM | Covered |
| C90.01 | ICD10CM | Covered |
| C90.02 | ICD10CM | Covered |
| C90.10 | ICD10CM | Covered |
| C90.20 | ICD10CM | Covered |
| C90.30 | ICD10CM | Covered |
| C91.10 | ICD10CM | Covered |
| D47.2 | ICD10CM | Covered |
| D63.8 | ICD10CM | Covered |
| D64.9 |