About this policy
Jurisdiction: J5 MAC Part B. States: Iowa, Kansas, Missouri, Nebraska. Type: Active LCD
Coverage indications
This policy defines coverage for Lab-Developed Tests (LDTs), Federal Drug Administration (FDA)-cleared, and FDA-approved clinical laboratory tests for hereditary thrombophilia including Next Generation Sequencing (NGS) tests. This policy’s scope is specific for hereditary germline testing. Criteria for Coverage Genetic testing for hereditary thrombophilia is covered when ALL of the following are met: The patient presents with venous thromboembolism (VTE) and at least 1 of the following is true: The patient presents with VTE that is associated with non-surgical major transient or hormonal risk factors (as defined in American Society of Hematology (ASH) guidelines), OR The patient presents with cerebral or splanchnic venous thrombosis, in settings where short term primary treatment is the standard of care (settings where anticoagulation would otherwise be discontinued) and testing will inform the decision for long-term anticoagulation. Genetic testing will guide VTE clinical management (e.g., duration of anticoagulation). The test performed includes at least the minimum genetic content (genes or genetic variants) with definitive or well-established guidelines-based evidence (as determined by American Society of Hematology) required for clinical decision making for its intended use that can be reasonably detected by the test. A single variant may be tested if it is the only variant considered to be reasonable and necessary for a patient given that it is a known familial variant. The test does not include additional genetic content that is not properly validated, or of unclear clinical validity or utility such that there could be reasonable expectation of misutilization by the patient or treating physician, resulting in impaired patient outcomes. The testing does not conflict with other applicable policy, specifically provisions of repeat germline testing defined in L38429. The test has satisfactorily completed a Technical Assessment (TA) by Molecular Diagnostic Services Program (MolDX ® ).
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 |
|---|---|---|
| 81240 | CPT | Covered |
| 81241 | CPT | Covered |
| 81479 | CPT | Covered |
| I26.02 | ICD10CM | Covered |
| I26.09 | ICD10CM | Covered |
| I26.92 | ICD10CM | Covered |
| I26.93 | ICD10CM | Covered |
| I26.94 | ICD10CM | Covered |
| I26.99 | ICD10CM | Covered |
| I27.82 | ICD10CM | Covered |
| I63.6 | ICD10CM | Covered |
| I67.6 | ICD10CM | Covered |