About this policy
Jurisdiction: JE Part B. States: California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands. Type: Active LCD
Coverage indications
This policy concerns the use of molecular diagnostic laboratory tests (tests of deoxyribonucleic acid (DNA), ribonucleic acid (RNA), and/or proteins) as a predictive classifier for non-small cell lung cancer (NSCLC). Molecular classifiers are considered reasonable and necessary when a beneficiary meets all of the following criteria: The patient has a non-squamous NSCLC with a tumor size i.e. American Joint Committee on Cancer Eighth Edition Stages I and IIa) The patient is sufficiently healthy to tolerate chemotherapy Adjuvant platinum-containing chemotherapy is being considered for the patient The test is ordered by a physician who is treating the patient for NSCLC (generally a medical oncologist, surgeon, or radiation oncologist) to help in the decision of whether or not to recommend adjuvant chemotherapy
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 |
|---|---|---|
| 81479 | CPT | Covered |
| 0288U | HCPCS | Covered |
| C34.01 | ICD10CM | Covered |
| C34.02 | ICD10CM | Covered |
| C34.11 | ICD10CM | Covered |
| C34.12 | ICD10CM | Covered |
| C34.2 | ICD10CM | Covered |
| C34.30 | ICD10CM | Covered |
| C34.31 | ICD10CM | Covered |
| C34.32 | ICD10CM | Covered |
| C34.81 | ICD10CM | Covered |
| C34.82 | ICD10CM | Covered |