Clinical Diagnostic Laboratory Services: CPT/HCPCS Codes

1 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Clinical Diagnostic Laboratory services : CPT/HCPCS Codes This list of Codes applies to the Medicare Advantage Policy Guideline titled Approval Date: October 13, 2021. Clinical Diagnostic Laboratory services . Applicable Codes The following list(s) of procedure and/or diagnosis Codes is provided for reference purposes only and may not be all inclusive. The listing of a code does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply. Not Covered When Lab NCD/MAPG.

2 Medicare Covered Submitted CPT/HCPCS Code (Payment Criteria Must Be Comments Preventive/Screening with Met). Screening Diagnosis 0002M- Liver dis 10 assays X. w/ash 0003M Liver dis 10 assays X. w/nash 0014M- Liver ds alys 3 bmrk X. srm alg (Effective 04/01/2020). 0015M- Adrnl cortcl tum bchm X. asy 25 (Effective 10/01/2020). 0016M- Onc bladder mrna X. 209 gen alg (Effective 10/01/2020). 0017M- Onc dlbcl mrna fluor X. prb hybrdztn 20 genes alg (Effective 01/01/2021). 0018M- Trnsplj rnl rjctn meas X. cd154+t cll whl prph bld (Effective 10/01/2021). 0002U- Onc clrct 3 ur metab X. alg plp 0007U- Rx test prsmv ur w/def X. conf 0008U- Hpylori detcj abx rstnc X. dna Clinical Diagnostic Laboratory services : CPT/HCPCS Codes Page 1 of 69. UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 10/13/2021. Proprietary Information of UnitedHealthcare.

3 Copyright 2021 United HealthCare services , Inc. Not Covered When Lab NCD/MAPG. Medicare Covered Submitted CPT/HCPCS Code (Payment Criteria Must Be Comments Preventive/Screening with Met). Screening Diagnosis 0010U- Nfct ds strn typ whl X. gen seq 0011U- Rx mntr lc-ms/ms oral X. fluid 0021U- Onc prst8 detcj 8 X. autoantb 0025U- Tenofovir liq chrom ur X. quan 0035U- Neuro csf prion prtn X. qual 0038U- Vitamin d srm X. microsamp quan 0041U- B brgdrferi antb 5 prtn X. igm 0042U- B brgdrferi antb 12 X. prtn igg 0043U- Tbrf b grp antb 4 prtn X. igm 0044U- Tbrf b grp antb 4 prtn X. igg 0051U- Rx mntr drugs present X. lc-ms/ms ur/bld 31 rx pnl 0052U- Lpoprtn bld w/5 maj X. classes 0054U- Rx mntr 14+ drugs & X. sbsts 0060U- Twn zyg gen seq alys X. chrms2. 0061U- Tc meas 5 bmrk sfdi X. m-s alys 0063U- Neuro autism 32 X. amines alg 0064U- Antb tp total&rpr ia X. qual 0065U- Syfls tst X.

4 Nontreponemal antb 0066U- Pamg-1 ia cervico-vag X. fluid 0068U- Candida species pnl X. amp prb 0077U- Ig paraprotein qual X. bld/ur Clinical Diagnostic Laboratory services : CPT/HCPCS Codes Page 2 of 69. UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 10/13/2021. Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare services , Inc. Not Covered When Lab NCD/MAPG. Medicare Covered Submitted CPT/HCPCS Code (Payment Criteria Must Be Comments Preventive/Screening with Met). Screening Diagnosis 0082U- Rx test def 90+ X. rx/sbsts ur 0086U- Nfct ds bact&fng org X. Id 6+. 0093U- Rx mntr 65 com drugs X. urine 0095U- Inflm ee elisa alys alg X. 0096U- Hpv hi risk types male X. urine 0106U- Gstr emptg 7 timed X. brth spec 0107U- C diff tox ag detcj ia X. stool 0109U- Id aspergillus dna 4 X. species 0110U- Rx mntr 1+oral onc X.

5 Rx&sbsts 0112U- Iadi 16s&18s rrna X. genes 0116U- Rx mntr nzm ia X. 35+oral flu 0117U- Pain mgmt 11 X. endogenous anal 0119U- Crd ceramides liq X. chrom plsm 0121U- Sc dis vcam-1 whole X. blood 0122U- Sc dis p-selectin whl X. blood 0123U- Mchnl fragility rbc X. prflg 0124U- Ftl cgen abnor 3. analytes (Deleted 06/30/2020). 0125U- Ftl cgen abnor prnt comp 5. (Deleted 06/30/2020). 0126U- Ftl cgen abnor prnt comp 5 y (Deleted 06/30/2020). 0127U- Ob pe 3 analytes (Deleted 06/30/2020). Clinical Diagnostic Laboratory services : CPT/HCPCS Codes Page 3 of 69. UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 10/13/2021. Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare services , Inc. Not Covered When Lab NCD/MAPG. Medicare Covered Submitted CPT/HCPCS Code (Payment Criteria Must Be Comments Preventive/Screening with Met).

6 Screening Diagnosis 0128U- Ob pe 3 analytes y chrmsm (Deleted 06/30/2020). 0139U- Neuro autism quan meas 6 ctr carbon metabolites (Deleted 10/01/2021). 0140U- Nfct ds fungi dna 15 X. trgt (Effective 01/01/2020). 0141U- Nfct Ds Bact&Fng X. Gram Pos (Effective 01/01/2020). 0142U- Nfct ds bact&fng gram X. neg (Effective 01/01/2020). 0143U- Drug assay 120+ X. rx/metablt (Effective 01/01/2020). 0144U- Drug assay 160+ X. rx/Metablt (Effective 01/01/2020). 0145U- Drug assay 65+ X. rx/Metablt (Effective 01/01/2020). 0146U- Drug assay y 80+ X. rx/Metablt (Effective 01/01/2020). 0147U- Drug assay 85+ X. rx/Metablt (Effective 01/01/2020). 0148U- Drug assay 100+ X. rx/Metablt (Effective 01/01/2020). 0149U- Drug assay 60+ X. rx/Metablt (Effective 01/01/2020). 0150U- Drug assay 120+ X. rx/Metablt (Effective 01/01/2020). 0152U- Nfct ds dna untrgt X. ngnrj seq (Effective 01/01/2020).

7 0163U- Onc clrct scr 3 prtn X. alg (Effective 04/01/2020). Clinical Diagnostic Laboratory services : CPT/HCPCS Codes Page 4 of 69. UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 10/13/2021. Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare services , Inc. Not Covered When Lab NCD/MAPG. Medicare Covered Submitted CPT/HCPCS Code (Payment Criteria Must Be Comments Preventive/Screening with Met). Screening Diagnosis 0164U- Gi Ibs Ia anti- X. cdtb&Vinculin (Effective 04/01/2020). 0165U- Peanut allg asmt epi X. (Effective 04/01/2020). 0166U- Liver ds 10 biochem X. asy srm (Effective 04/01/2020). 0167U- Chornc gonadotropin X. hcg ia (Effective 04/01/2020). 0174U- Onc solid tum mass X. spectrometric 30 protein trgt (Effective 07/01/2020). 0176U- Cdtb & vinculin igg X. antibodies by immunoassay (Effective 07/01/2020).

8 0178U- Peanut allg spec asmt X. mlt epi elisa bld clin rxn (Effective 07/01/2020). 0206U- Neuro Alzheimer cell X. aggregj (Effective 10/01/2020). 0207U- Neuro Alzheimer quan X. imaging (Effective 10/01/2020). 0210U- syphilis tst antb ia X. quan (Effective 10/01/2020). 0219U- Nfct agt hiv gnrj seq X. alys (Effective 10/01/2020). 0220U- Onc brst ca ai assmt X. 12 feat (Effective 10/01/2020). 0224U- Antb sev aqt respir synd coronavirus 2 Titer(S). (Effective 06/25/2020). 0226U- Svnt sarscov2 elisa plsm srm (Effective 08/10/2020). 0227U- Rx asy prsmv X. 30+rx/metablt (Effective 01/01/2021). 0243U- Ob pe biochem asy X. plcntl grwth factr mat srm alg (Effective 04/01/2021). Clinical Diagnostic Laboratory services : CPT/HCPCS Codes Page 5 of 69. UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 10/13/2021. Proprietary Information of UnitedHealthcare.

9 Copyright 2021 United HealthCare services , Inc. Not Covered When Lab NCD/MAPG. Medicare Covered Submitted CPT/HCPCS Code (Payment Criteria Must Be Comments Preventive/Screening with Met). Screening Diagnosis 0244U- Onc solid orgn dna X. compre genomic prflg 257. gene (Effective 04/01/2021). 0246U- Rbc dna gnotyp 16 X. bld grp phnt predict 51 rbc ag (Effective 04/01/2021). 0247U- Ob preterm birth ibp4 X. shbg quan meas mat srm prs (Effective 04/01/2021). 0248U- Onc brn sphrd cll 12 X. rx pnl (Effective 07/01/2021). 0249U- Onc brst alys 32 X. phsprtn alg (Effective 07/01/2021). 0250U- Onc sld org neo dna X. 505 gene (Effective 07/01/2021). 0251U- Hepcidin-25 elisa X. serum/plsm (Effective 07/01/2021). 0252U- Ftl aneuploidy str alys X. dna (Effective 07/01/2021). 0253U- Rprdtve med rna gen X. prfl 238. (Effective 07/01/2021). 0254U- Reprdtve med alys 24 X. chrmsm (Effective 07/01/2021).

10 0255U- Andrology infertility X. sperm capacitation assmt (Effective 10/01/2021). 0256U- Tma/tmao profile X. ms/ms urine alg alys&report (Effective 10/01/2021). 0257U- Vlcad leukocyte X. enzyme activity whole blood (Effective 10/01/2021). 0258U- Ai psoriasis mrna gen X. xprsn prfl 50-100 gen alg (Effective 10/01/2021). 0259U- Nephrology ckd X. nuclear mrs meas gfr srm Quan (Effective 10/01/2021). Clinical Diagnostic Laboratory services : CPT/HCPCS Codes Page 6 of 69. UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 10/13/2021. Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare services , Inc. Not Covered When Lab NCD/MAPG. Medicare Covered Submitted CPT/HCPCS Code (Payment Criteria Must Be Comments Preventive/Screening with Met). Screening Diagnosis 0260U- Rare ds id vrtj invrj insj X. tlcj opt genome mapg (Effective 10/01/2021).