About this policy
Jurisdiction: J5 MAC Part B. States: Iowa, Kansas, Missouri, Nebraska. Type: Active LCD
Coverage indications
Molecular diagnostic tests used to assist in risk stratification of melanoma patients are covered when ALL of the following are true: The patient has a personal history of melanoma AND: Either: Has Stage T1b and above OR Has T1a with documented concern about adequacy of microstaging Is undergoing workup or being evaluated for treatment, AND Does not have metastatic disease AND Presumed risk for a positive Sentinel Lymph Node Biopsy (SLNB) based on clinical, histological, or other information is >5% AND Has a disease stage, grade, and Breslow thickness (or other qualifying conditions) within the intended use of the test The TEST has demonstrated, as part of a Technical Assessment: Clinical validity of analytes tested in predicting metastatic disease (or the absence of metastatic disease) in peer-reviewed scientific literature Utility beyond clinical, histological, and radiographical factors in the ability to accurately stratify patients into risk groups to manage patient care, such by precluding unnecessary sentinel lymph node biopsies Appropriate analytical validity Performance characteristics equivalent or superior to other covered, similar tests
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 |
| 81529 | CPT | Covered |
| 81599 | CPT | Covered |
| 0578U | HCPCS | Covered |
| C43.0 | ICD10CM | Covered |
| C43.10 | ICD10CM | Covered |
| C43.111 | ICD10CM | Covered |
| C43.112 | ICD10CM | Covered |
| C43.121 | ICD10CM | Covered |
| C43.122 | ICD10CM | Covered |
| C43.20 | ICD10CM | Covered |
| C43.21 | ICD10CM | Covered |