Molecular and Genomic Testing Program Update: October 2023
As part of our Molecular and Genomic Testing Program, eviCore healthcare (eviCore) performs pre-service medical necessity determination (MND) reviews of certain services to be provided to our members.
- For services to be rendered on and after October 18, 2023 in a physician’s office or clinical laboratory, eviCore will also conduct pre-service MND reviews of the services represented by the following, recently added Proprietary Laboratory Analyses (PLA) codes.
| Code | Description |
|---|---|
| 0403U | Oncology (prostate), MRNA, gene expression profiling of 18 genes, first-catch post-digital rectal examination urine (or processed first-catch urine), algorithm reported as percentage of likelihood of detecting clinically significant prostate cancer |
| 0405U | Oncology (pancreatic), 59 methylation haplotype block markers, next-generation sequencing, plasma, reported as cancer signal detected or not detected |
| 0409U | Oncology (solid tumor), DNA (80 genes) and RNA (36 genes), by next-generation sequencing from plasma, including single nucleotide variants, insertions/deletions, copy number alterations, microsatellite instability, and fusions, report showing identified mutations with clinical actionability |
| 0410U | Oncology (pancreatic), DNA, whole genome sequencing with 5-hydroxymethylcytosine enrichment, whole blood or plasma, algorithm reported as cancer detected or not detected |
| 0411U | Psychiatry (eg, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6 |
| 0413U | Oncology (hematolymphoid neoplasm), optical genome mapping for copy number alterations, aneuploidy, and balanced/complex structural rearrangements, DNA from blood or bone marrow, report of clinically significant alterations |
| 0414U | Oncology (lung), augmentative algorithmic analysis of digitized whole slide imaging for 8 genes (ALK, BRAF, EGFR, ERBB2, MET, NTRK1-3, RET, ROS1), and KRAS G12C and PD-L1, if performed, formalin-fixed paraffin-embedded (FFPE) tissue, reported as positive or negative for each biomarker |
| 0417U | Rare diseases (constitutional/heritable disorders), whole mitochondrial genome sequence with heteroplasmy detection and deletion analysis, nuclear-encoded mitochondrial gene analysis of 335 nuclear genes, including sequence changes, deletions, insertions, and copy number variants analysis, blood or saliva, identification and categorization of mitochondrial disorder–associated genetic variants |
| 0418U | Oncology (breast), augmentative algorithmic analysis of digitized whole slide imaging of 8 histologic and immunohistochemical features, reported as a recurrence score |
| 0419U | Neuropsychiatry (eg, depression, anxiety), genomic sequence analysis panel, variant analysis of 13 genes, saliva or buccal swab, report of each gene phenotype |
- Effective October 1, 2023, eviCore will no longer conduct pre-service MND reviews of the services represented by the following procedure codes.
| Code | Description |
|---|---|
| 0386U | Gastroenterology (Barrett’s esophagus), P16, RUNX3, HPP1, and FBN1 methylation analysis, prognostic and predictive algorithm reported as a risk score for progression to high-grade dysplasia or esophageal cancer |
| 0397U | Oncology (non-small cell lung cancer), cell-free DNA from plasma, targeted sequence analysis of at least 109 genes, including sequence variants, substitutions, insertions, deletions, select rearrangements, and copy number variations |
Review the complete list of molecular and genomic diagnostic testing services subject to MND review as part of this program or review more details about our Molecular and Genomic Testing Program.
If you have questions, please contact your Network Specialist or Ancillary Contracting Specialist
eviCore healthcare is an independent company that supports Horizon BCBSNJ in the provision of Medical Necessity Review (PA/MND) of certain molecular and genomic diagnostic testing services that are rendered in a physician’s office or clinical laboratory setting.
MND requirements do not apply to molecular and genomic diagnostic testing services rendered to patients in a hospital Emergency Room, hospital outpatient or inpatient setting or an Ambulatory Surgery Center (ASC).
CPT® is a registered trademark of the American Medical Association.