81528 No Reimbursable for recipients 50 75 of age. For No more – recipients outside this age range, providers must than once Oncology (colorectal) submit a TAR documenting medical necessity. every two screening, quantitative years * real-time target and signal amplification of 10 DNA * For recipients requiring additional tests within a markers (KRAS mutations, year, providers must submit a TAR documenting promoter methylation of medical necessity. NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result 81545 Yes Oncology, when billed with CPT-4 code 81545 (oncology with Algorithmic Analyses [thyroid], gene any Multianalyte Assays With expression analysis of 142 genes, utilizing fine provider, Algorithmic Analyses needle aspirate, algorithm reported as a except with categorical result) requires a TAR and has a valid TAR frequency limit. override The following criteria must be documented on the TAR: Thyroid nodule that is cytologically indeterminate on fine-needle aspiration The diagnostic or treatment strategy will be contingent on test results 81520, 81521, 81599 Yes Gene expression profiling for breast cancer may be As noted billed with CPT-4 code 81518 (oncology [breast], Gene Expression Profiling mRNA, gene expression profiling by real time for Breast Cancer of 11 genes, utilizing formalin-fixed Continued embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy), 81519 (oncology [breast], mRNA, gene expression profiling by real time RT-PCR of 21
81528 Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result No Reimbursable for recipients 50 – 75 of age. For recipients outside this age range, providers must submit a TAR documenting medical necessity. * For recipients requiring additional tests within a year, providers must submit a TAR documenting medical necessity. No more than once every two years * 81545 Multianalyte Assays With Algorithmic Analyses Yes Oncology, when billed with CPT-4 code 81545 (oncology with Algorithmic Analyses [thyroid], gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as a categorical result) requires a TAR and has a frequency limit. The following criteria must be documented on the TAR: Thyroid nodule that is cytologically indeterminate on fine-needle aspiration The diagnostic or treatment strategy will be contingent on test results any provider, except with valid TAR override 81520, 81521, 81599 Gene Expression Profiling for Breast Cancer Continued Yes Gene expression profiling for breast cancer may be billed with CPT-4 code 81518 (oncology [breast], mRNA, gene expression profiling by real time of 11 genes, utilizing formalin-fixed tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy), 81519 (oncology [breast], mRNA, gene expression profiling by real time RT-PCR of 21 embedded As noted