About this policy
Jurisdiction: JJ Part B. States: Alabama, Georgia, Tennessee. Type: Active LCD
Coverage indications
This policy describes and clarifies coverage for Lab-Developed Tests (LDTs) and Food and Drug Administration (FDA)-approved or cleared clinical laboratory tests utilizing Next-Generation Sequencing (NGS) in cancer as allowable under the National Coverage Determination (NCD) 90.2, under section D describing Medicare Administrative Contractor (MAC) discretion for coverage, as well as for use of NGS in suspected myeloid neoplasms. This policy’s scope is specific for myeloid malignancies and suspected malignancies, and is exclusive of solid tumor testing, circulating tumor DNA (ctDNA) testing, and other cancer-related uses of NGS, such as in germline testing.
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 |
|---|---|---|
| 81170 | CPT | Covered |
| 81450 | CPT | Covered |
| 81451 | CPT | Covered |
| 81455 | CPT | Covered |
| 81456 | CPT | Covered |
| 81479 | CPT | 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 |