About this policy
Jurisdiction: JF Part B. States: Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming. Type: Active LCD
Coverage indications
This test is a “liquid biopsy". It is intended to assist physicians caring for patients who suffer from a common form of lung cancer and who have advanced disease. This policy provides limited coverage for InvisionFirst ® - Lung (Inivata ™ , Research Triangle Park, NC) (hereafter InVision ® ) a plasma-based, somatic comprehensive genomic profiling (CGP) test for patients with advanced (Stage IIIB/IV) non-small cell lung cancer (NSCLC): At diagnosis When results for EGFR single nucleotide variants (SNVs) and insertions and deletions (indels); rearrangements in ALK and ROS1; and SNVs for BRAF are not available AND when tissue-based CGP is infeasible [i.e., quantity not sufficient (QNS) for tissue-based CGP or invasive biopsy is medically contraindicated], or At progression For patients progressing on or after chemotherapy or immunotherapy who have not been tested for EGFR SNVs and indels; rearrangements in ALK and ROS1; and SNVs for BRAFs, and for whom tissue-based CGP is infeasible; or For patients progressing on EGFR tyrosine kinase inhibitors (TKIs). If no genetic alteration is detected by InVision ® or if circulating tumor DNA (ctDNA) is insufficient/not detected, tissue-based genotyping should be considered.
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 |
| 0388U | HCPCS | Covered |
| C33 | ICD10CM | Covered |
| C34.01 | ICD10CM | Covered |
| C34.02 | ICD10CM | Covered |
| C34.11 | ICD10CM | Covered |
| C34.12 | ICD10CM | Covered |
| C34.2 | ICD10CM | Covered |
| C34.31 | ICD10CM | Covered |
| C34.32 | ICD10CM | Covered |
| C34.81 | ICD10CM | Covered |
| C34.82 | ICD10CM | Covered |