CLINICAL DIAGNOSTIC LABORATORY SERVICES: CPT CODES · 2020-02-28 · Clinical Diagnostic Laboratory...
Transcript of CLINICAL DIAGNOSTIC LABORATORY SERVICES: CPT CODES · 2020-02-28 · Clinical Diagnostic Laboratory...
Clinical Diagnostic Laboratory Services: CPT Codes Page 1 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CLINICAL DIAGNOSTIC LABORATORY SERVICES:
CPT CODES
Approval Date: February 12, 2020
This list of codes applies to the policy titled Clinical Diagnostic Laboratory Services.
APPLICABLE CODES
This list 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.
CPT Code
Medicare
Covered Preventive/Screening
Lab NCD/MPG (Payment Criteria Must Be Met)
Not Covered When
Submitted with
Screening Diagnosis
Comments
0001M-Infectious disease (Deleted 01/01/2019)
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0002M-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0003M-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0004M-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0006M-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0007M-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0009M-Molecular Pathology (Deleted 12/31/2019)
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0011M-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0012M-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0013M-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
UnitedHealthcare® Medicare Advantage
Policy Appendix: Applicable Code List
Clinical Diagnostic Laboratory Services: CPT Codes Page 2 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
0001U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0002U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0003U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0005U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0006U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0007U-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0008U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0009U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0010U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0011U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0012U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0013U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0014U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0016U-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0017U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0018U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0019U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0020U-Drug metabolism, DNA (Deleted 10/01/2018)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 3 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
0021U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0022U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0023U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0024U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0025U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0026U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0027U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0028U-Drug metabolism, CYP2D6 (Deleted 10/01/2018)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0029U-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0030U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0031U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0032U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0033U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0034U-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0035U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0036U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0037U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0038U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 4 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
0039U-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0040U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0041U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0042U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0043U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0044U-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0045U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0046U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0047U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0048U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0049U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0050U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0051U-Prescription drug monitoring, LC-MS/MS
X
0052U-Lipoprotein, W/5 Maj Classes
X
0053U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0054U-Prescription drug monitoring, 14+
X
0055U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0056U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0057U-Oncology (solid organ)
(Expired 06/30/2019) Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 5 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
0058U-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0059U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0060U-Twin zygosity, DNA X
0061U-Molecular Pathology X
0062U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0063U-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0064U-Molecular Diagnostic X
0065U-Molecular Diagnostic X
0066U-Placental alpha-micro globulin-1
X
0067U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0068U-Molecular Diagnostic X
0069U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0070U-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0071U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0072U-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0073U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0074U-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0075U-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0076U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0077U-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0078U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0079U-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 6 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
0080U-Oncology (lung) (Effective 01/01/2019)
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0081U-Oncology (uveal melanoma) (Deleted 12/31/2019)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0082U-Drug test(s), 90+ drugs
or substances (Effective 01/01/2019)
X
0083U-Oncology, motility contrast tomography response) (Effective 01/01/2019)
X
0084U-Rbc Dna Gnotyp 10 Bld
Groups (Effective 07/01/2019)
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0085U-Cdtb&Vinculin Igg Antb Ia (Effective 07/01/2019)
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0086U-Nfct Ds Bact&Fng Org Id 6+ (Effective 07/01/2019)
Refer to: Molecular Diagnostic Infectious Disease Testing
0087U-Crd Hrt Trnspl Mrna 1283 Gen (Effective 07/01/2019)
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0088U-Trnsplj Kdn Algrft Rej 1494 (Effective 07/01/2019)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0089U-Onc Mlnma Prame & Linc00518 (Effective
07/01/2019)
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0090U-Onc Cutan Mlnma Mrna 23 Gene (Effective 07/01/2019)
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0092U-Onc Lng 3 Prtn Bmrk
Plsm Alg (Effective 07/01/2019)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0093U-Rx Mntr 65 Com Drugs Urine (Effective 07/01/2019)
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0094U-Genome Rapid Sequence Alys (Effective 07/01/2019)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0095U-Inflm Ee Elisa Alys Alg (Effective 07/01/2019)
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0096U-Hpv Hi Risk Types Male Urine (Effective 07/01/2019)
Refer to: Molecular Diagnostic Infectious Disease Testing
0097U-Gi Pathogen 22 Targets (Effective 07/01/2019)
Refer to: Molecular Diagnostic Infectious Disease Testing
0098U-Respir Pathogen 14 Targets (Effective 07/01/2019)
Refer to: Molecular Diagnostic Infectious Disease Testing
0099U-Respir Pathogen 20 Targets (Effective 07/01/2019)
Refer to: Molecular Diagnostic Infectious Disease Testing
0100U-Respir Pathogen 20 Targets (Effective 07/01/2019)
Refer to: Molecular Diagnostic Infectious Disease Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 7 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
0101U-Hered Colon Ca Do 15 Genes (Effective 07/01/2019)
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0102U-Hered Brst Ca Rltd Do 17 Gen (Effective 07/01/2019
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0103U-Hered Ova Ca Pnl 24
Genes (Effective 07/01/2019) Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0104U-Hered Pan Ca Pnl 32 Genes (Deleted 10/01/2019)
0105U-Neph Ckd Mult Eclia Tum Nec (Effective 10/01/2019)
X
0106U-Gstr emptg 7 timed brth spec (Effective 10/01/2019)
X
0107U-C diff tox ag detcj ia stool (Effective 10/01/2019)
X
0108U-Gi barrett esoph 9 prtn bmrk (Effective 10/01/2019)
X
0109U-Id aspergillus dna 4 species (Effective 10/01/2019)
X
0110U-Rx mntr 1+oral onc rx&sbsts (Effective 10/01/2019)
X
0111U-Onc colon ca kras&nras alys (Effective 10/01/2019)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0112U-Iadi 16s&18s rrna genes (Effective 10/01/2019)
X
0113U-Onc prst8 pca3&tmprss2-erg (Effective 10/01/2019)
X
0114U-Gi barretts esoph vim&ccna1 (Effective 10/01/2019)
X
0115U-Respir iadna 18 viral&2 bact (Effective 10/01/2019)
Refer to: Molecular Diagnostic Infectious Disease Testing
0116U-Rx mntr nzm ia 35+oral flu (Effective 10/01/2019)
X
0117U-Pain mgmt 11 endogenous anal (Effective 10/01/2019)
X
0118U-Trnsplj don-drv cll-fr dna
(Effective 10/01/2019)
X
0119U-Crd ceramides liq chrom
plsm (Effective 10/01/2019)
X
0120U-Onc b cll lymphm mrna
58 gen (Effective 10/01/2019)
X
0121U-Sc dis vcam-1 whole blood (Effective 10/01/2019)
X
0122U-Sc dis p-selectin whl
blood (Effective 10/01/2019)
X
0123U-Mchnl fragility rbc prflg (Effective 10/01/2019)
X
0124U-Ftl cgen abnor 3 analytes
(Effective 10/01/2019)
X
0125U-Ftl cgen abnor prnt comp 5 (Effective 10/01/2019)
X
Clinical Diagnostic Laboratory Services: CPT Codes Page 8 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
0126U-Ftl cgen abnor prnt comp 5 y (Effective 10/01/2019)
X
0127U-Ob pe 3 analytes (Effective 10/01/2019)
X
0128U-Ob pe 3 analytes y chrmsm (Effective 10/01/2019)
X
0129U-Hered brst ca rltd do panel (Effective 10/01/2019)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0130U-Hered colon ca do mrna pnl (Effective 10/01/2019)
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0131U-Hered brst ca rltd do pnl
13 (Effective 10/01/2019)
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0132U-Hered ova ca rltd do pnl 17 (Effective 10/01/2019)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0133U-Hered prst8 ca rltd do 11 (Effective 10/01/2019)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0134U-Hered pan ca mrna pnl 18 gen (Effective 10/01/2019)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0135U-Hered gyn ca mrna pnl
12 gen (Effective 10/01/2019) Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0136U-Atm mrna seq alys
(Effective 10/01/2019)
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0137U-Palb2 mrna seq alys (Effective 10/01/2019)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0138U-Brca1 brca2 mrna seq alys (Effective 10/01/2019)
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0139U-Neuro Austm Meas 6 C Metablt (Effective 01/01/2020)
X
0140U-Nfct Ds Fungi Dna 15
Trgt (Effective 01/01/2020)
X
0141U-Nfct Ds Bact&Fng Gram Pos (Effective 01/01/2020)
X
0142U-Nfct Ds Bact&Fng Gram
Neg (Effective 01/01/2020)
X
0143U-Drug Assay 120+ Rx/Metablt (Effective 01/01/2020)
X
0144U-Drug Assay 160+
Rx/Metablt (Effective 01/01/2020)
X
0145U-Drug Assay 65+ Rx/Metablt (Effective 01/01/2020)
X
0146U-Drug Assay 80+ Rx/Metablt (Effective 01/01/2020)
X
Clinical Diagnostic Laboratory Services: CPT Codes Page 9 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
0147U-Drug Assay 85+ Rx/Metablt (Effective
01/01/2020)
X
0148U-Drug Assay 100+ Rx/Metablt (Effective 01/01/2020)
X
0149U-Drug Assay 60+
Rx/Metablt (Effective 01/01/2020)
X
0150U-Drug Assay 120+ Rx/Metablt (Effective 01/01/2020)
X
0151U-Nfct Bct/Vir Resp Nfctj 33
(Effective 01/01/2020)
X
0152U-Nfct Bct Fng Prst Dna >1000 (Effective 01/01/2020)
X
0153U-Onc Breast Mrna 101 Genes (Effective 01/01/2020)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0154U-Fgfr3 Gene Analysis (Effective 01/01/2020)
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0155U-Pik3ca Gene Analysis (Effective 01/01/2020)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0156U-Copy Number Sequence
Alys (Effective 01/01/2020) Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
0157U-Apc Mrna Seq Alys (Effective 01/01/2020)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0158U-Mlh1 Mrna Seq Alys
(Effective 01/01/2020) Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0159U-Mlh1 Mrna Seq Alys
(Effective 01/01/2020) Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
0160U-Msh6 Mrna Seq Alys
(Effective 01/01/2020) Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0161U-Pms2 Mrna Seq Alys
(Effective 01/01/2020) Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
0162U-Hered Colon Ca Trgt Mrna Pnl (Effective 01/01/2020)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
80047-Multi-Test Laboratory Panels
X
80048- Multi-Test Laboratory Panels
X
80050-Multi-Test Laboratory Panels-General health panel
Never Covered
80051-Multi-Test Laboratory Panels
X
80053- Multi-Test Laboratory Panels
X
Clinical Diagnostic Laboratory Services: CPT Codes Page 10 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
80055- Multi-Test Laboratory Panels
X
80061-Multi-Test Laboratory Panels-Lipid panel
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.23 Lipids
Testing
80069-Multi-Test Laboratory Panels
X
80074-Multi-Test Laboratory
Panels
See CMS: Clinical Diagnostic
Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.33 Hepatitis Panel/Acute Hepatitis Panel
80076-Multi-Test Laboratory Panels
X
80081-Multi-Test Laboratory Panels-Obstetric Panel
NCD 210.7 Screening for HIV Infection
80150-Therapeutic Drug Levels X
80155-Therapeutic Drug Levels X
80156-Therapeutic Drug Levels X
80157-Therapeutic Drug Levels X
80158-Therapeutic Drug Levels X
80159-Therapeutic Drug Levels X
80162-Therapeutic Drug Levels
See CMS: Clinical Diagnostic
Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.24 Digoxin Therapeutic Drug Assay
80163-Therapeutic Drug Levels X
80164-Therapeutic Drug Levels X
80165-Therapeutic Drug Levels X
80168-Therapeutic Drug Levels X
80169-Therapeutic Drug Levels X
80170-Therapeutic Drug Levels X
80171-Therapeutic Drug Levels X
80173-Therapeutic Drug Levels X
80175-Therapeutic Drug Levels X
80176-Therapeutic Drug Levels X
80177-Therapeutic Drug Levels X
80178-Therapeutic Drug Levels X
80180-Therapeutic Drug Levels X
80183-Therapeutic Drug Levels X
80184-Therapeutic Drug Levels X
80185-Therapeutic Drug Levels X
80186-Therapeutic Drug Levels X
80188-Therapeutic Drug Levels X
80190-Therapeutic Drug Levels X
Clinical Diagnostic Laboratory Services: CPT Codes Page 11 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
80192-Therapeutic Drug Levels X
80194-Therapeutic Drug Levels X
80195-Therapeutic Drug Levels X
80197-Therapeutic Drug Levels X
80198-Therapeutic Drug Levels X
80199-Therapeutic Drug Levels X
80200-Therapeutic Drug Levels X
80201-Therapeutic Drug Levels X
80202-Therapeutic Drug Levels X
80203-Therapeutic Drug Levels X
80299-Therapeutic Drug Levels X
80305-Drug Screens Refer to: Qualitative Drug
Testing for Indications Other Than Mental Health
80306-Drug Screens Refer to: Qualitative Drug Testing for Indications Other
Than Mental Health
80307-Drug Screens Refer to: Qualitative Drug Testing for Indications Other Than Mental Health
80320-Drug Screens Invalid
80321-Drug Screens Invalid
80322-Drug Screens Invalid
80323-Drug Screens Invalid
80324-Drug Screens Invalid
80325-Drug Screens Invalid
80326-Drug Screens Invalid
80327-Drug Screens Invalid
80328-Drug Screens Invalid
80329-Drug Screens Invalid
80330-Drug Screens Invalid
80331-Drug Screens Invalid
80332-Drug Screens Invalid
80333-Drug Screens Invalid
80334-Drug Screens Invalid
80335-Drug Screens Invalid
80336-Drug Screens Invalid
80337-Drug Screens Invalid
80338-Drug Screens Invalid
80339-Drug Screens Invalid
80340-Drug Screens Invalid
80341-Drug Screens Invalid
80342-Drug Screens Invalid
80343-Drug Screens Invalid
80344-Drug Screens Invalid
80345-Drug Screens Invalid
80346-Drug Screens Invalid
Clinical Diagnostic Laboratory Services: CPT Codes Page 12 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
80347-Drug Screens Invalid
80348-Drug Screens Invalid
80349-Drug Screens Invalid
80350-Drug Screens Invalid
80351-Drug Screens Invalid
80352-Drug Screens Invalid
80353-Drug Screens Invalid
80354-Drug Screens Invalid
80355-Drug Screens Invalid
80356-Drug Screens Invalid
80357-Drug Screens Invalid
80358-Drug Screens Invalid
80359-Drug Screens Invalid
80360-Drug Screens Invalid
80361-Drug Screens Invalid
80362-Drug Screens Invalid
80363-Drug Screens Invalid
80364-Drug Screens Invalid
80365-Drug Screens Invalid
80366-Drug Screens Invalid
80367-Drug Screens Invalid
80368-Drug Screens Invalid
80369-Drug Screens Invalid
80370-Drug Screens Invalid
80371-Drug Screens Invalid
80372-Drug Screens Invalid
80373-Drug Screens Invalid
80374-Drug Screens Invalid
80375-Drug Screens Invalid
80376-Drug Screens Invalid
80377-Drug Screens Invalid
80400-Stimulation and Suppression Test Panels
X
80402-Stimulation and
Suppression Test Panels
X
80406-Stimulation and Suppression Test Panels
X
80408-Stimulation and
Suppression Test Panels
X
80410-Stimulation and Suppression Test Panels
X
80412-Stimulation and
Suppression Test Panels
X
80414-Stimulation and Suppression Test Panels
X
80415-Stimulation and Suppression Test Panels
X
Clinical Diagnostic Laboratory Services: CPT Codes Page 13 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
80416-Stimulation and Suppression Test Panels
X
80417-Stimulation and Suppression Test Panels
X
80418-Stimulation and Suppression Test Panels
X
80420-Stimulation and Suppression Test Panels
X
80422-Stimulation and Suppression Test Panels
X
80424-Stimulation and Suppression Test Panels
X
80426-Stimulation and
Suppression Test Panels
X
80428-Stimulation and
Suppression Test Panels
X
80430-Stimulation and Suppression Test Panels
X
80432-Stimulation and
Suppression Test Panels
X
80434-Stimulation and Suppression Test Panels
X
80435-Stimulation and
Suppression Test Panels
X
80436-Stimulation and Suppression Test Panels
X
80438-Stimulation and Suppression Test Panels
X
80439-Stimulation and Suppression Test Panels
X
81000-Urine Tests X
81001-Urine Tests X
81002-Urine Tests X
81003-Urine Tests X
81005-Urine Tests X
81007-Urine Tests X
81015-Urine Tests X
81020-Urine Tests X
81025-Urine Tests X
81050-Urine Tests X
81099-Urine Tests X
81105-Molecular Pathology Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81106-Molecular Pathology Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81107-Molecular Pathology Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81108-Molecular Pathology Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81109-Molecular Pathology Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 14 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
81110-Molecular Pathology Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81111-Molecular Pathology Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81112-Molecular Pathology Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81120-Molecular Pathology Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81121-Molecular Pathology Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81161-Molecular Pathology Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81162-Molecular Pathology Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81163-Molecular Pathology Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81164-Molecular Pathology Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81165-Molecular Pathology Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81166-Molecular Pathology Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81167-Molecular Pathology Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81170-Molecular Pathology Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81171-Molecular Pathology Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81172-Molecular Pathology Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81173-Molecular Pathology Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81174-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81175-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 15 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
81176-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81177-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81178-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81179-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81180-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81181– Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81182– Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81183-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81184-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81185-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81186-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81187-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81188-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81189-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81190-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81200-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81201-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81202-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 16 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
81203-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81204-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81205-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81206-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81207-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81208-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81209-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81210-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81211-Molecular Pathology (Deleted 01/01/2019)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81212-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81213-Molecular Pathology
(Deleted 01/01/2019) Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81214-Molecular Pathology (Deleted 01/01/2019)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81215-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81216– Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81217-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81218-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81219-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81220-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 17 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
81221-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81222-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81223-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81224-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81225-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81226-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81227-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81228-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81229-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81230-Cytochrome
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81231-Cytochrome
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81232-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81233-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81234-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81235-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81236-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81237-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81238-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 18 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
81239-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81240-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81241-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81242-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81243-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81244-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81245-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81246-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81247-G6PD
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81248-G6PD
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81249-G6PD
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81250-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81251-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81252-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81253-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81254-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81255-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81256-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 19 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
81257-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81258-HBA1/HBA2
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81259-HBA1/HBA2
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81260-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81261-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81262-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81263-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81264-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81265-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81266-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81267-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81268-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81269-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81270-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81271-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81272-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81273-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81274-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 20 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
81275-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81276-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81283-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81284-FXN (frataxin)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81285-FXN (frataxin)
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81286-FXN (frataxin)
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81287-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81288-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81289-FXN (frataxin)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81290-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81291-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81292-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81293-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81294-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81295-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81296-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81297-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81298-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 21 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
81299-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81300-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81301-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81302-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81303-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81304-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81305-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81306-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81310-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81311-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81312-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81313-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81314-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81315-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81316-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81317-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81318-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81319-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 22 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
81320-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81321-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81322-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81323-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81324-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81325-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81326-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81327-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81328-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81329-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81330-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81331-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81332-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81333-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81334-Runt related transcription
factor 1
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81335-TPMT
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81336-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81337-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 23 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
81340-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81341-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81342-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81343-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81344-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81345-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81346-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81350-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81355-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81361-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81362-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81363-Hemoglobin, subunit beta
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81364-Hemoglobin, subunit beta
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81370-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81371-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81372-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81373-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81374-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 24 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
81375-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81376-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81377-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81378-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81379-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81380-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81381-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81382-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81383-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81400-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81401-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81402-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81403-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81404-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81405-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81406-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81407-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81408-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 25 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
81410-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81411-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81412-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81413-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81414-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81415-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81416-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81417-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81420-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81422-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81425-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81426-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81427-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81430-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81431-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81432-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81433-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81434-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 26 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
81435-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81436-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81437-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81438-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81439-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81440-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81442-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81443-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81445-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81448-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81450-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81455-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81460-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81465-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81470-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81471-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81479-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81490-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81493-Coronary artery disease, mRNA
X
Clinical Diagnostic Laboratory Services: CPT Codes Page 27 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
81500-Multianalyte Assays with Algorithmic Analyses (MAAA)
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81503-Multianalyte Assays with Algorithmic Analyses (MAAA)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81504-Multianalyte Assays with
Algorithmic Analyses (MAAA) Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81506-Multianalyte Assays with Algorithmic Analyses (MAAA)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81507-Multianalyte Assays with
Algorithmic Analyses (MAAA)
X
81508-Multianalyte Assays with Algorithmic Analyses (MAAA)
X
81509-Multianalyte Assays with Algorithmic Analyses (MAAA)
X
81510-Multianalyte Assays with Algorithmic Analyses (MAAA)
X
81511-Multianalyte Assays with Algorithmic Analyses (MAAA)
X
81512-Multianalyte Assays with Algorithmic Analyses (MAAA)
X
81518-Multianalyte Assays with
Algorithmic Analyses (MAAA) Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81519-Multianalyte Assays with
Algorithmic Analyses (MAAA)
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81520-Multianalyte Assays with Algorithmic Analyses (MAAA)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81521-Multianalyte Assays with Algorithmic Analyses (MAAA)
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81525-Multianalyte Assays with Algorithmic Analyses (MAAA)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81528-Oncology (colorectal) screening
NCD 210.3 Colorectal Cancer Screening Tests
81535-Oncology (gynecologic)
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81536-Oncology (gynecologic)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81538-Oncology (lung)
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81539-Oncology (high-grade prostated cancer)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81540-Oncology (tumor of unknown origin)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 28 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
81541-Oncology (prostate), mRNA
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
81545-Oncology (thyroid)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81551-Oncology (prostate)
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
81595-Multianalyte Assays with Algorithmic Analyses (MAAA)
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
81596-Multianalyte Assays with
Algorithmic Analyses (MAAA) (Effective 01/01/2019)
Refer to: Molecular Diagnostic
Infectious Disease Testing
81599-Unlisted multianalyte assay with algorithmic analysis
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
82009-Chemistry X
82010-Chemistry X
82013-Chemistry X
82016-Chemistry X
82017-Chemistry X
82024-Chemistry X
82030-Chemistry X
82040-Chemistry X
82042-Chemistry X
82043-Chemistry X
82044-Chemistry X
82045-Chemistry X
82075-Chemistry X
82085-Chemistry X
82088-Chemistry X
82103-Chemistry X
82104-Chemistry X
82105-Chemistry: Alcohol-Alpha-fetoprotein (AFP)
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage
Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.25 Alpha-fetoprotein
82106-Chemistry x
82107-Chemistry x
82108-Chemistry x
82120-Chemistry x
82127-Chemistry x
82128-Chemistry x
82131-Chemistry x
Clinical Diagnostic Laboratory Services: CPT Codes Page 29 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
82135-Chemistry x
82136-Chemistry x
82139-Chemistry x
82140-Chemistry x
82143-Chemistry x
82150-Chemistry x
82154-Chemistry x
82157-Chemistry x
82160-Chemistry x
82163-Chemistry x
82164-Chemistry x
82172-Chemistry: Apolipoprotein
Refer to: Biomarkers in Cardiovascular Risk Assessment
82175-Chemistry X
82180-Chemistry X
82190-Chemistry X
82232-Chemistry X
82239-Chemistry X
82240-Chemistry X
82147-Chemistry X
82148-Chemistry X
82252-Chemistry X
82161-Chemistry X
82270-Chemistry: Occult Blood
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.34 Fecal Occult Blood Test NCD 210.3 Colorectal Cancer
Screening Tests
82271-Chemistry: Occult Blood X
82272-Chemistry: Occult Blood
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage
Determinations (NCD) Coding
Policy Manual and Change Report; NCD 190.34 Fecal Occult Blood Test
82274-Chemistry: Occult Blood X
82286-Chemistry X
82300-Chemistry X
82306-Chemistry X
82308-Chemistry X
82310-Chemistry X
82330-Chemistry X
82331-Chemistry X
Clinical Diagnostic Laboratory Services: CPT Codes Page 30 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
82340-Chemistry X
82355-Chemistry X
82360-Chemistry X
82365-Chemistry X
82370-Chemistry X
82373-Chemistry X
82374-Chemistry X
82375-Chemistry X
82376-Chemistry X
82378-Carcinoembryonic antigen
(CEA)
See CMS: Clinical Diagnostic
Laboratory Services, Medicare National Coverage
Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.26 Carcinoembryonic Antigen
82379-Chemistry X
82380-Chemistry X
82382-Chemistry X
82383-Chemistry X
82384-Chemistry X
82387-Chemistry X
82390-Chemistry X
82397-Chemistry X
82415-Chemistry X
82435-Chemistry X
82436-Chemistry X
82438-Chloride; other source NCD 190.5 Sweat Test
82441-Chemistry: Chlorinated Hydrocarbons
X
82465-Chemistry: Cholesterol, Total
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.23 Lipids Testing
82480-Chemistry X
82482-Chemistry X
82485-Chemistry X
82495-Chromium
NCD 300.1 Obsolete or Unreliable Diagnostic Tests
82507-Citrate X
Clinical Diagnostic Laboratory Services: CPT Codes Page 31 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
82523-Chemistry: Collagen Crosslinks, Any Method
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.19 Collagen Crosslinks, Any Method
82525-Chemistry X
82528-Chemistry X
82530-Chemistry X
82533-Chemistry X
82540-Chemistry X
82542-Chemistry X
82550-Chemistry X
82552-Chemistry X
82553-Chemistry X
82554-Chemistry X
82565-Chemistry X
82570-Chemistry X
82575-Chemistry X
82585-Chemistry X
82595-Chemistry X
82600-Chemistry X
82607-Chemistry X
82608-Chemistry X
82610-Chemistry: Cryoglobulin-Dibucaine
Refer to: Biomarkers in Cardiovascular Risk Assessment
82615-Chemistry X
82626-Chemistry X
82627-Chemistry X
82633-Chemistry X
82634-Chemistry X
82638-Chemistry X
82642-Chemistry X
82652-Chemistry X
82656-Chemistry X
82657-Chemistry X
82658-Chemistry X
82664-Chemistry X
82668-Chemistry X
82670-Chemistry X
82671-Chemistry X
82672-Chemistry X
82677-Chemistry X
82679-Chemistry X
Clinical Diagnostic Laboratory Services: CPT Codes Page 32 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
82693-Chemistry X
82696-Chemistry X
82705-Chemistry X
82710-Chemistry X
82715-Chemistry X
82725-Chemistry X
82726-Chemistry X
82728-Chemistry: Ferritin
See CMS: Clinical Diagnostic
Laboratory Services, Medicare National Coverage Determinations (NCD) Coding
Policy Manual and Change Report; NCD 190.18 Serum Iron Studies
82731-Chemistry X
82735-Chemistry X
82746-Chemistry X
82747-Chemistry X
82757-Chemistry X
82759-Chemistry X
82760-Chemistry X
82775-Chemistry X
82776-Chemistry X
82777-Chemistry X
82784-Chemistry X
82785-Chemistry X
82787-Chemistry X
82800-Chemistry X
82803-Chemistry X
82805-Chemistry X
82810-Chemistry X
82820-Chemistry X
82930-Chemistry X
82938-Chemistry X
82941-Chemistry X
82943-Chemistry X
82945-Chemistry X
82946-Chemistry X
82947-Chemistry: Glucose Testing
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.20 Blood Glucose Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 33 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
82948-Chemistry: Glucose Testing
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.20 Blood Glucose Testing
82950-Chemistry: Glucose
Testing X
82951-Chemistry: Glucose Testing
X
82952-Chemistry X
82955-Chemistry X
82960-Chemistry X
82962-Chemistry: Glucose Testing
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.20 Blood Glucose Testing
82963-Chemistry X
82965-Chemistry X
82977-Chemistry: Glutamyltransferase, gamma (GGT)
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage
Determinations (NCD) Coding
Policy Manual and Change Report; NCD 190.32 Gamma Glutamyl Transferase
82978-Chemistry X
82979-Chemistry X
82985-Chemistry: Glycated protein
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding
Policy Manual and Change Report; NCD 190.21 Glycated Hemoglobin/Glycated Protein
83001-Chemistry X
83002-Chemistry X
83003-Chemistry X
83006-Chemistry X
83009-Chemistry X
83010-Chemistry X
83012-Chemistry X
83013-Chemistry X
83014-Chemistry X
83015-Chemistry X
83018-Chemistry X
83020-Chemistry X
Clinical Diagnostic Laboratory Services: CPT Codes Page 34 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
83021-Chemistry X
83026-Chemistry X
83030-Chemistry X
83033-Chemistry X
83036-Chemistry: Hemoglobin;
glycosylated (A1C)
See CMS: Clinical Diagnostic
Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.21 Glycated Hemoglobin/Glycated Protein
83037-Chemistry X
83045-Chemistry X
83050-Chemistry X
83051-Chemistry X
83060-Chemistry X
83065-Chemistry X
83068-Chemistry X
83069-Chemistry X
83070-Chemistry X
83080-Chemistry X
83088-Chemistry X
83090 Chemistry: Homocysteine
Refer to: Biomarkers in Cardiovascular Risk Assessment
83150-Chemistry X
83491-Chemistry X
83497-Chemistry X
83498-Chemistry X
83500-Chemistry X
83505-Chemistry X
83516-Chemistry X
83518-Chemistry X
83519-Chemistry X
83520-Chemistry X
83525-Chemistry X
83527-Chemistry X
83528-Chemistry X
83540-Chemistry: Iron
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change
Report; NCD 190.18 Serum Iron Studies
Clinical Diagnostic Laboratory Services: CPT Codes Page 35 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
83550-Chemistry: Iron Binding Capacity
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.18 Serum Iron Studies
83570-Chemistry X
83582-Chemistry X
83586-Chemistry X
83593-Chemistry X
83605-Chemistry X
83615-Chemistry X
83625-Chemistry X
83630-Chemistry X
83631-Chemistry X
83632-Chemistry X
83633-Chemistry X
83655-Chemistry X
83661-Chemistry X
83662-Chemistry X
83663-Chemistry X
83664-Chemistry X
83670-Chemistry X
83690-Chemistry X
83695-Lipoprotein (a)
Refer to: Biomarkers in Cardiovascular Risk Assessment
83698-Lipoprotein-associated phospholipase A2 (Lp-PLA2)
Refer to: Biomarkers in Cardiovascular Risk Assessment
83700-Lipoprotein, blood; electrophoretic separation and quantitation
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage
Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.23 Lipids Testing Or refer to: Biomarkers in Cardiovascular Risk Assessment
83701- Lipoprotein blood; high resolution fractionation and quantitation of lipoproteins
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.23 Lipids Testing
Or refer to: Biomarkers in Cardiovascular Risk Assessment
Clinical Diagnostic Laboratory Services: CPT Codes Page 36 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
83704-Lipoprotein, blood; quantitation of lipoprotein
particle number
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.23 Lipids Testing Or refer to: Biomarkers in Cardiovascular Risk Assessment
83718-Lipoprotein, direct measurement; high density cholesterol
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding
Policy Manual and Change Report; NCD 190.23 Lipids
Testing
83719-Lipoprotein, direct measurement; VLDL cholesterol
Refer to: Biomarkers in Cardiovascular Risk Assessment
83721-Lipoprotein, direct
measurement; LDL cholesterol
See CMS: Clinical Diagnostic
Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.23 Lipids Testing Or refer to: Biomarkers in
Cardiovascular Risk Assessment
83722-Chemistry X
83727-Chemistry X
83735-Chemistry X
83775-Chemistry X
83785-Chemistry X
83789-Chemistry X
83825-Chemistry X
83835-Chemistry X
83857-Chemistry X
83861-Chemistry X
83864-Chemistry X
83872-Chemistry X
83873-Chemistry X
83874-Chemistry X
83876-Chemistry X
83880-Chemistry X
83883-Chemistry X
83885-Chemistry X
83915-Chemistry X
83916-Chemistry X
83918-Chemistry X
83919-Chemistry X
83921-Chemistry X
Clinical Diagnostic Laboratory Services: CPT Codes Page 37 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
83930-Chemistry X
83935-Chemistry X
83937-Chemistry X
83945-Chemistry X
83950-Chemistry X
83951-Chemistry X
83970-Chemistry X
83986-Chemistry X
83987-Chemistry X
83992-Assay for Phencyclidine
Invalid
04/01/2018
83993-Chemistry X
84030-Chemistry X
84035-Chemistry X
84060-Chemistry X
84066-Chemistry X
84075-Chemistry X
84078-Chemistry X
84080-Chemistry X
84081-Chemistry X
84085-Chemistry X
84087-Chemistry X
84100-Chemistry X
84105-Chemistry X
84106-Chemistry X
84110-Chemistry X
84112-Chemistry X
84119-Chemistry X
84120-Chemistry X
84126-Chemistry X
84132-Chemistry X
84133-Chemistry X
84134-Chemistry X
84135-Chemistry X
84138-Chemistry X
84140-Chemistry X
84143-Chemistry X
84144-Chemistry X
84145-Chemistry X
84146-Chemistry X
84150-Chemistry X
84152-Chemistry X
Clinical Diagnostic Laboratory Services: CPT Codes Page 38 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
84153-Chemistry: Prostate Specific Antigen
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.31 Prostate Specific Antigen
84154-Chemistry X
84155-Chemistry X
84156-Chemistry X
84157-Chemistry X
84160-Chemistry X
84163-Chemistry X
84165-Chemistry X
84166-Chemistry X
84181-Chemistry X
84182-Chemistry X
84202-Chemistry X
84203-Chemistry X
84206-Chemistry X
84207-Chemistry X
84210-Chemistry X
84220-Chemistry X
84228-Chemistry X
84233-Chemistry X
84234-Chemistry X
84235-Chemistry X
84238-Chemistry X
84244-Chemistry X
84252-Chemistry X
84255-Chemistry X
84260-Chemistry X
84270-Chemistry X
84275-Chemistry X
84285-Chemistry X
84295-Chemistry X
84300-Chemistry X
84302-Chemistry X
84305-Chemistry X
84307-Chemistry X
84311-Chemistry X
84315-Chemistry X
84375-Chemistry X
84376-Chemistry X
84377-Chemistry X
Clinical Diagnostic Laboratory Services: CPT Codes Page 39 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
84378-Chemistry X
84379-Chemistry X
84392-Chemistry X
84402-Chemistry X
84403-Chemistry X
84410-Chemistry X
84425-Chemistry X
84430-Chemistry X
84431-Chemistry X
84432-Chemistry X
84436-Chemistry: Thyroid Tests
See CMS: Clinical Diagnostic
Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.22 Thyroid Testing
84437-Chemistry: Thyroid Tests X
84439-Chemistry: Thyroid Tests
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding
Policy Manual and Change Report; NCD 190.22 Thyroid Testing
84442-Chemistry: Thyroid Tests X
84443-Chemistry: Thyroid Tests
See CMS: Clinical Diagnostic
Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.22 Thyroid Testing
84445-Chemistry X
84446-Chemistry X
84449-Chemistry X
84450-Chemistry X
84460-Chemistry X
84466-Chemistry: Transferrin
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.18 Serum Iron Studies
84478-Chemistry: Triglycerides
See CMS: Clinical Diagnostic
Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.23 Lipids Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 40 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
84479-Chemistry: Thyroid Hormone
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.22 Thyroid Testing
84480-Chemistry X
84481-Chemistry X
84482-Chemistry X
84484-Chemistry X
84485-Chemistry X
84488-Chemistry X
84490-Chemistry X
84510-Chemistry X
84512-Chemistry X
84520-Chemistry X
84525-Chemistry X
84540-Chemistry X
84545-Chemistry X
84550-Chemistry X
84560-Chemistry X
84577-Chemistry X
84578-Chemistry X
84580-Chemistry X
84583-Chemistry X
84585-Chemistry X
84586-Chemistry X
84588-Chemistry X
84590-Chemistry X
84591-Chemistry-NOS Vitamin Never Covered
84597-Chemistry X
84600-Chemistry X
84620-Chemistry X
84630-Chemistry X
84681-C-peptide X
84702-Gonadotropin, chorionic; quantitative
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.27 Human
Chorionic Gonadotropin
84703-Gonadotropin X
84704-Gonadotropin X
84830-Ovulation tests X
Clinical Diagnostic Laboratory Services: CPT Codes Page 41 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
84999- Unlisted chemistry procedure
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing NCD 190.7 Human Tumor Stem Cell Drug Sensitivity Assays
85002-Hematology; Bleeding Time Test
X
85004-Blood Counts
See CMS: Clinical Diagnostic
Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.15 Blood
Counts
85007-Blood Counts
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.15 Blood
Counts
85008-Blood Counts
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change
Report; NCD 190.15 Blood Counts
85009-Hematology; Blood Counts
X
85013-Blood Counts
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.15 Blood Counts
85014-Blood Counts
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change
Report; NCD 190.15 Blood Counts
85018- Blood Counts
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding
Policy Manual and Change Report; NCD 190.15 Blood Counts
Clinical Diagnostic Laboratory Services: CPT Codes Page 42 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
85025-Blood Counts
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.15 Blood Counts
85027-Hematology; Blood
Counts
X
85032-Blood Counts
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding
Policy Manual and Change Report; NCD 190.15 Blood Counts
85041-Hematology; Blood Counts
X
85044-Hematology; Blood Counts
X
85045-Hematology; Blood Counts
X
85046-Hematology; Blood Counts
X
85048-Blood Counts
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding
Policy Manual and Change Report; NCD 190.15 Blood Counts
85049-Blood Counts
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.15 Blood Counts
85055-Hematology;
Coagulopathy Testing
X
85060-Hematology; Coagulopathy Testing
X
85097-Hematology;
Coagulopathy Testing
X
85130-Hematology; Coagulopathy Testing
X
85170-Hematology; Coagulopathy Testing
X
85175-Hematology; Coagulopathy Testing
X
85210-Hematology; Coagulopathy Testing
X
85220-Hematology; Coagulopathy Testing
X
85230-Hematology; Coagulopathy Testing
X
Clinical Diagnostic Laboratory Services: CPT Codes Page 43 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
85240-Hematology; Coagulopathy Testing
X
85244-Hematology; Coagulopathy Testing
X
85245-Hematology; Coagulopathy Testing
X
85246-Hematology; Coagulopathy Testing
X
85247-Hematology; Coagulopathy Testing
X
85250-Hematology; Coagulopathy Testing
X
85260-Hematology;
Coagulopathy Testing
X
85270-Hematology;
Coagulopathy Testing
X
85280-Hematology; Coagulopathy Testing
X
85290-Hematology;
Coagulopathy Testing
X
85291-Hematology; Coagulopathy Testing
X
85292-Hematology;
Coagulopathy Testing
X
85293-Hematology; Coagulopathy Testing
X
85300-Hematology; Coagulopathy Testing
X
85301-Hematology; Coagulopathy Testing
X
85302-Hematology; Coagulopathy Testing
X
85303-Hematology; Coagulopathy Testing
X
85305-Hematology; Coagulopathy Testing
X
85306-Hematology; Coagulopathy Testing
X
85307-Hematology; Coagulopathy Testing
X
85335-Hematology; Coagulopathy Testing
X
85337-Hematology;
Coagulopathy Testing
X
85345-Hematology;
Coagulopathy Testing
X
85347-Hematology; Coagulopathy Testing
X
85348-Hematology;
Coagulopathy Testing
X
85360-Hematology; Coagulopathy Testing
X
85362-Hematology;
Coagulopathy Testing
X
85366-Hematology; Coagulopathy Testing
X
Clinical Diagnostic Laboratory Services: CPT Codes Page 44 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
85370-Hematology; Coagulopathy Testing
X
85378-Hematology; Coagulopathy Testing
X
85379-Hematology; Coagulopathy Testing
X
85380-Hematology; Coagulopathy Testing
X
85384-Hematology; Coagulopathy Testing
X
85385-Hematology; Coagulopathy Testing
X
85390-Hematology;
Coagulopathy Testing
X
85396-Hematology;
Coagulopathy Testing
X
85397-Hematology; Coagulopathy Testing
X
85400-Hematology;
Coagulopathy Testing
X
85410-Hematology; Coagulopathy Testing
X
85415-Hematology;
Coagulopathy Testing
X
85420-Hematology; Coagulopathy Testing
X
85421-Hematology; Coagulopathy Testing
X
85441-Hematology; Coagulopathy Testing
X
85445-Hematology; Coagulopathy Testing
X
85460-Hematology; Coagulopathy Testing
X
85461-Hematology; Coagulopathy Testing
X
85475-Hematology; Coagulopathy Testing
X
85520-Hematology; Coagulopathy Testing
X
85525-Hematology; Coagulopathy Testing
X
85530-Hematology;
Coagulopathy Testing
X
85536-Hematology;
Coagulopathy Testing
X
85540-Hematology; Coagulopathy Testing
X
85547-Coagulopathy Testing
Mechanical Fragility
Investigational
Deny
85549-Hematology; Coagulopathy Testing
X
85555-Hematology;
Coagulopathy Testing
X
85557-Hematology; Coagulopathy Testing
X
Clinical Diagnostic Laboratory Services: CPT Codes Page 45 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
85576-Hematology; Coagulopathy Testing
X
85597-Hematology; Coagulopathy Testing
X
85598-Hematology; Coagulopathy Testing
X
85610-Coagulopathy Testing
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.17
Prothrombin Time (PT)
85611-Hematology; Coagulopathy Testing
X
85612-Hematology; Coagulopathy Testing
X
85613-Hematology; Coagulopathy Testing
X
85635-Hematology; Coagulopathy Testing
X
85651-Hematology; Coagulopathy Testing
X
85652-Hematology; Coagulopathy Testing
X
85660-Hematology; Coagulopathy Testing
X
85670-Hematology;
Coagulopathy Testing
X
85675-Hematology; Coagulopathy Testing
X
85705-Hematology; Coagulopathy Testing
X
85730-Partial Thromboplastin Time (PTT)Thromboplastin time, partial
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.16 Partial Thromboplastin Time (PTT)
85732-Partial Thromboplastin Time (PTT)
X
85810-Blood Viscosity X
85999-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
86000-Immunology X
86001-Immunology X
86003-Immunology X
86005-Immunology X
86008-Immunology X
86021-Immunology X
86022-Immunology X
86023-Immunology X
Clinical Diagnostic Laboratory Services: CPT Codes Page 46 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
86038-Immunology X
86039-Immunology X
86060-Immunology X
86063-Immunology X
86077-Blood Bank Services X
86078-Blood Bank Services X
86079-Blood Bank Services X
86140-C-Reactive Protein
(hsCRP)
Refer to: Biomarkers in
Cardiovascular Risk Assessment
86141-C-Reactive Protein (hsCRP)
Refer to: Biomarkers in Cardiovascular Risk Assessment
86146-Immunology X
86147-Immunology X
86148-Immunology X
86152-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
86153-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
86155-Immunology X
86156-Immunology X
86157-Immunology X
86160-Immunology X
86161-Immunology X
86162-Immunology X
86171-Immunology X
86200-Immunology X
86215-Immunology X
86225-Immunology X
86226-Immunology X
86235-Immunology X
86255-Immunology X
86256-Immunology X
86277-Immunology X
86280-Immunology X
86294-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
86300-Diagnostic Immunology Testing
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.29 Tumor Antigen by Immunoassay CA 15-3/CA 27.29
Clinical Diagnostic Laboratory Services: CPT Codes Page 47 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
86301-Diagnostic Immunology Testing
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.30 Tumor Antigen by Immunoassay CA 19-9
86304-Diagnostic Immunology Testing
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change
Report; NCD 190.28 Tumor Antigen by Immunoassay CA
125
86305-Immunology X
86308-Immunology X
86309-Immunology X
86310-Immunology X
86316-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
86317-Immunology X
86318-Immunology X
86320-Immunology X
86325-Immunology X
86327-Immunology X
86329-Immunology X
86331-Immunology X
86332-Immunology X
86334-Immunology X
86335-Immunology X
86336-Immunology X
86337-Immunology X
86340-Immunology X
86341-Immunology X
86343-Immunology X
86344-Immunology X
86352-Assay Cellular Function
NCD 190.8 Lymphocyte Mitogen Response Assays
86353-Assay Cellular Function
NCD 190.8 Lymphocyte Mitogen
Response Assays
86355-Immunology X
86356-Immunology X
86357-Immunology X
86359-Immunology X
86360-Immunology X
86361-Immunology X
Clinical Diagnostic Laboratory Services: CPT Codes Page 48 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
86367-Immunology X
86376-Immunology X
86382-Immunology X
86384-Immunology X
86386-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
86403-Immunology X
86406-Immunology X
86430-Immunology X
86431-Immunology X
86480-Immunology X
86481-Immunology X
86485-Immunology X
86486-Immunology X
86490-Immunology X
86510-Immunology X
86580-Immunology X
86590-Immunology X
86592-Syphilis Testing NCD 210.10 Screening for STIs
86593-Syphilis Testing NCD 210.10 Screening for STIs
86602-Infectious Testing X
86603-Infectious Testing X
86606-Infectious Testing X
86609-Infectious Testing X
86611-Infectious Testing X
86612-Infectious Testing X
86615-Infectious Testing X
86617-Infectious Testing X
86618-Infectious Testing X
86619-Infectious Testing X
86622-Infectious Testing X
86625-Infectious Testing X
86628-Infectious Testing X
86631-Antibody; Chlamydia NCD 210.10 Screening for STIs
86632-Antibody; Chlamydia NCD 210.10 Screening for STIs
86635-Infectious Testing X
86638-Infectious Testing X
86641-Infectious Testing X
86644-Infectious Testing X
86645-Infectious Testing X
86648-Infectious Testing X
86651-Infectious Testing X
86652-Infectious Testing X
Clinical Diagnostic Laboratory Services: CPT Codes Page 49 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
86653-Infectious Testing X
86654-Infectious Testing X
86658-Infectious Testing X
86663-Infectious Testing X
86664-Infectious Testing X
86665-Infectious Testing X
86666-Infectious Testing X
86668-Infectious Testing X
86671-Infectious Testing X
86674-Infectious Testing X
86677-Infectious Testing X
86682-Infectious Testing X
86684-Infectious Testing X
86687-Infectious Testing X
86688-Infectious Testing X
86689-Testing for Antibodies to Infectious Agents
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding
Policy Manual and Change Report; NCD 190.14 HIV Testing, Diagnostic
86692-Infectious Testing X
86694-Infectious Testing X
86695-Infectious Testing X
86696-Infectious Testing X
86698-Infectious Testing X
86701-Testing for HIV Antibodies
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change
Report; NCD 190.14 HIV Testing, Diagnostic
86702-Testing for HIV Antibodies
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding
Policy Manual and Change Report; NCD 190.14 HIV Testing, Diagnostic
86703-Testing for HIV Antibodies
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.14 HIV Testing, Diagnostic
86704-Hepatitis B
NCD 210.6 Screening for
Hepatitis B Virus Infection
Clinical Diagnostic Laboratory Services: CPT Codes Page 50 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
86705-Hepatitis B
NCD 210.6 Screening for Hepatitis B Virus Infection
86706-Hepatitis B
NCD 210.6 Screening for Hepatitis B Virus Infection
86707-Infectious Testing X
86708-Infectious Testing X
86709-Infectious Testing X
86710-Infectious Testing X
86711-Infectious Testing X
86713-Infectious Testing X
86717-Infectious Testing X
86720-Infectious Testing X
86723-Infectious Testing X
86727-Infectious Testing X
86732-Infectious Testing X
86735-Infectious Testing X
86738-Infectious Testing X
86741-Infectious Testing X
86744-Infectious Testing X
86747-Infectious Testing X
86750-Infectious Testing X
86753-Infectious Testing X
86756-Infectious Testing X
86757-Infectious Testing X
86759-Infectious Testing X
86762-Infectious Testing X
86765-Infectious Testing X
86768-Infectious Testing X
86771-Infectious Testing X
86774-Infectious Testing X
86777-Infectious Testing X
86778-Infectious Testing X
86780-Antibody; Treponema pallidum
NCD 210.10 Screening for STIs
86784-Infectious Testing X
86787-Infectious Testing X
86788-Infectious Testing X
86789-Infectious Testing X
86790-Infectious Testing X
86793-Infectious Testing X
86794-Infectious Testing X
86800-Infectious Testing X
86803-Infectious Testing X
86804-Infectious Testing X
Clinical Diagnostic Laboratory Services: CPT Codes Page 51 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
86805-Histocompatibility Testing
NCD 190.1 Histocompatibility Testing
86806-Histocompatibility Testing
NCD 190.1 Histocompatibility Testing
86807-Histocompatibility Testing
NCD 190.1 Histocompatibility Testing
86808-Histocompatibility Testing
NCD 190.1 Histocompatibility Testing
86812-Histocompatibility Testing
NCD 190.1 Histocompatibility Testing
86813-Histocompatibility Testing
NCD 190.1 Histocompatibility Testing
86816-Histocompatibility Testing
NCD 190.1 Histocompatibility
Testing
86817-Histocompatibility Testing
NCD 190.1 Histocompatibility
Testing
86821-Histocompatibility Testing
NCD 190.1 Histocompatibility Testing
86825-Histocompatibility Testing
NCD 190.1 Histocompatibility
Testing
86826-Histocompatibility Testing
NCD 190.1 Histocompatibility Testing
86828-Histocompatibility Testing X
86829-Histocompatibility Testing X
86830-Histocompatibility Testing X
86831-Histocompatibility Testing X
86832-Histocompatibility Testing X
86833-Histocompatibility Testing X
86834-Histocompatibility Testing X
86835-Histocompatibility Testing X
86849- Unlisted immunology procedure
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing NCD 190.7 Human Tumor Stem Cell Drug Sensitivity Assays
NCD 300.1 Obsolete or Unreliable Diagnostic Tests
86850-Transfusion Services X
86860-Transfusion Services X
86870-Transfusion Services X
86880-Transfusion Services X
86885-Transfusion Services X
86886-Transfusion Services X
86890-Transfusion Services X
86891-Transfusion Services X
86900-Transfusion Services X
86901-Transfusion Services X
86902-Transfusion Services X
86904-Transfusion Services X
86905-Transfusion Services X
Clinical Diagnostic Laboratory Services: CPT Codes Page 52 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
86906-Transfusion Services X
86910-Transfusion Services Never Covered
86911-Transfusion Services Never Covered
86920-Transfusion Services X
86921-Transfusion Services X
86922-Transfusion Services X
86923-Transfusion Services X
86927-Transfusion Services X
86930-Transfusion Services X
86931-Transfusion Services X
86932-Transfusion Services X
86940-Transfusion Services X
86941-Transfusion Services X
86945-Transfusion Services X
86950-Transfusion Services X
86960-Transfusion Services X
86965-Transfusion Services X
86970-Transfusion Services X
86971-Transfusion Services X
86972-Transfusion Services X
86975-Transfusion Services X
86976-Transfusion Services X
86977-Transfusion Services X
86978-Transfusion Services X
86985-Transfusion Services X
86999-Transfusion Services X
87003-Identification of
Microorganisms
X
87015-Identification of Microorganisms
X
87040-Identification of
Microorganisms
X
87045-Identification of Microorganisms
X
87046-Identification of Microorganisms
X
87070-Identification of Microorganisms
X
87071-Identification of Microorganisms
X
87073-Identification of Microorganisms
X
87075-Identification of Microorganisms
X
87076-Identification of Microorganisms
X
87077-Identification of Microorganisms
X
Clinical Diagnostic Laboratory Services: CPT Codes Page 53 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
87081-Identification of Microorganisms
X
87084-Identification of Microorganisms
X
87086-Culture, bacterial; quantitative, colony count, urine
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage
Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.12 Urine Culture, Bacterial
87088-Culture, bacterial; with
isolation and presumptive
identification of each isolates, urine
See CMS: Clinical Diagnostic
Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.12 Urine Culture, Bacterial
87101-Identification of Microorganisms
X
87102-Identification of Microorganisms
X
87103-Identification of Microorganisms
X
87106-Identification of Microorganisms
X
87107-Identification of
Microorganisms
X
87109-Identification of Microorganisms
X
87110-Identification of
Microorganisms
X
87116-Identification of Microorganisms
X
87118-Identification of Microorganisms
X
87140-Identification of Microorganisms
X
87143-Identification of Microorganisms
X
87147-Identification of Microorganisms
X
87149-Identification of
Microorganisms
X
87150-Identification of Microorganisms
X
87152-Identification of Microorganisms
X
87153-Identification of Microorganisms
X
87158-Identification of Microorganisms
X
87164-Identification of Microorganisms
X
87166-Identification of Microorganisms
X
Clinical Diagnostic Laboratory Services: CPT Codes Page 54 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
87168-Identification of Microorganisms
X
87169-Identification of Microorganisms
X
87172-Identification of Microorganisms
X
87176-Identification of Microorganisms
X
87177-Identification of Microorganisms
X
87181-Identification of Microorganisms
X
87184-Identification of
Microorganisms
X
87185-Identification of
Microorganisms
X
87186-Identification of Microorganisms
X
87187-Identification of
Microorganisms
X
87188-Identification of Microorganisms
X
87190-Identification of
Microorganisms
X
87197-Identification of Microorganisms
X
87205-Identification of Microorganisms
X
87206-Identification of Microorganisms
X
87207-Identification of Microorganisms
X
87209-Identification of Microorganisms
X
87210-Identification of Microorganisms
X
87220-Identification of Microorganisms
X
87230-Identification of Microorganisms
X
87250-Identification of Microorganisms
X
87252-Identification of
Microorganisms
X
87253-Identification of
Microorganisms
X
87254-Identification of Microorganisms
X
87255-Identification of
Microorganisms
X
87260-Identification of Microorganisms
X
87265-Identification of
Microorganisms
X
87267-Identification of Microorganisms
X
Clinical Diagnostic Laboratory Services: CPT Codes Page 55 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
87269-Identification of Microorganisms
X
87270-Infectious agent antigen detection by immunofluorescent technique
NCD 210.10 Screening for STIs
87271-Fluorescence Microscopy by Organism
X
87272-Fluorescence Microscopy by Organism
X
87273-Fluorescence Microscopy by Organism
X
87274-Fluorescence Microscopy by Organism
X
87275-Fluorescence Microscopy by Organism
X
87276-Fluorescence Microscopy by Organism
X
87278-Microbiology X
87279-Microbiology X
87280-Microbiology X
87281-Microbiology X
87283-Microbiology X
87285-Microbiology X
87290-Microbiology X
87299-Microbiology X
87300-Microbiology X
87301-Microbiology X
87305-Microbiology X
87320-Infectious agent antigen detection by enzyme immunoassay technique
NCD 210.10 Screening for STIs
87324-Microbiology X
87327-Microbiology X
87328-Microbiology X
87329-Microbiology X
87332-Microbiology X
87335-Microbiology X
87336-Microbiology X
87337-Microbiology X
87338-Microbiology X
87339-Microbiology X
87340-Infectious agent antigen
detection by immunoassay technique
NCD 210.6 Screening for
Hepatitis B Virus (HBV) Infection
87341-Infectious agent antigen detection by immunoassay technique
NCD 210.6 Screening for Hepatitis B Virus (HBV) Infection
87350-Microbiology X
87380-Microbiology X
Clinical Diagnostic Laboratory Services: CPT Codes Page 56 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
87385-Microbiology X
87389-Microbiology X
87390-Infectious agent antigen detection by immunoassay technique
X
87391-Infectious agent antigen
detection by immunoassay technique
X
87400-Infectious agent antigen detection by immunoassay technique
X
87420-Infectious agent antigen detection by immunoassay
technique
X
87425-Infectious agent antigen detection by immunoassay
technique
X
87427-Infectious agent antigen detection by immunoassay technique
X
87430-Infectious agent antigen detection by immunoassay technique
X
87449-Infectious agent antigen detection by immunoassay technique
X
87450-Infectious agent antigen detection by immunoassay
technique
X
87451-Infectious agent antigen
detection by immunoassay technique
X
87471-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87472-Infectious agent detection
by nucleic acid
Refer to: Molecular Diagnostic
Infectious Disease Testing
87475-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87476-Infectious agent detection
by nucleic acid
Refer to: Molecular Diagnostic
Infectious Disease Testing
87477-Infectious agent detection by nucleic acid
X
87480-Infectious agent detection
by nucleic acid
Refer to: Molecular Diagnostic
Infectious Disease Testing
87481-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87482-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87483-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87485-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87486-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87487-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 57 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
87490-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
NCD 210.10 Screening for STIs
87491-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing NCD 210.10 Screening for STIs
87492-Detection Infectious
Agent
Refer to: Molecular Diagnostic
Infectious Disease Testing
87493-Detection Infectious Agent
Refer to: Molecular Diagnostic Infectious Disease Testing
87495-Detection Infectious
Agent
Refer to: Molecular Diagnostic
Infectious Disease Testing
87496-Infectious agent detection
by nucleic acid (DNA or RNA)
Refer to: Molecular Diagnostic
Infectious Disease Testing
87497-Infectious agent detection by nucleic acid (DNA or RNA)
Refer to: Molecular Diagnostic Infectious Disease Testing
87498-Infectious agent detection by nucleic acid (DNA or RNA)
Refer to: Molecular Diagnostic Infectious Disease Testing
87500-Infectious agent detection by nucleic acid (DNA or RNA)
Refer to: Molecular Diagnostic Infectious Disease Testing
87501-Infectious agent detection by nucleic acid (DNA or RNA)
Refer to: Molecular Diagnostic Infectious Disease Testing
87502-Infectious agent detection by nucleic acid (DNA or RNA)
Refer to: Molecular Diagnostic Infectious Disease Testing
87503-Infectious agent detection by nucleic acid (DNA or RNA)
Refer to: Molecular Diagnostic Infectious Disease Testing
87505-Infectious agent detection by nucleic acid (DNA or RNA)
Refer to: Molecular Diagnostic Infectious Disease Testing
87506-Infectious agent detection by nucleic acid (DNA or RNA)
Refer to: Molecular Diagnostic Infectious Disease Testing
87507-Infectious agent detection by nucleic acid (DNA or RNA)
Refer to: Molecular Diagnostic Infectious Disease Testing
87510-Infectious agent detection by nucleic acid (DNA or RNA)
Refer to: Molecular Diagnostic Infectious Disease Testing
87511-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87512-Infectious agent detection
by nucleic acid
Refer to: Molecular Diagnostic
Infectious Disease Testing
87516-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87517-Infectious agent detection
by nucleic acid
Refer to: Molecular Diagnostic
Infectious Disease Testing
87520-Infectious agent detection
by nucleic acid
Refer to: Molecular Diagnostic
Infectious Disease Testing
87521-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87522-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87525-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87526-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87527-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87528-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 58 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
87529-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87530-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87531-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87532-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87533-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87534-Detection Infectious Agent by Probe Techniques
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage
Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.14 HIV Testing, Diagnostic
Or refer to: Molecular Diagnostic Infectious Disease Testing
87535-Detection Infectious Agent by Probe Techniques
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage
Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.14 HIV Testing, Diagnostic Or refer to: Molecular Diagnostic Infectious Disease Testing
87536-Detection Infectious Agent, HIV-1
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.13 HIV Testing, Monitoring
Or refer to: Molecular Diagnostic Infectious Disease Testing
87537-Detection Infectious Agent by Probe Techniques
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage
Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.14 HIV Testing, Diagnostic
Or refer to: Molecular Diagnostic Infectious Disease Testing
87538-Detection Infectious Agent by Probe Techniques
See CMS: Clinical Diagnostic Laboratory Services, Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.14 HIV
Testing, Diagnostic Or refer to: Molecular Diagnostic Infectious Disease Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 59 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
87539-Detection Infectious Agent, HIV-2
See CMS: Clinical Diagnostic Laboratory Services, Medicare
National Coverage Determinations (NCD) Coding Policy Manual and Change Report; NCD 190.13 HIV Testing, Monitoring Or refer to: Molecular Diagnostic Infectious Disease Testing
87540-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87541-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87542-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87550-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87551-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87552-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87555-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87556-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87557-Infectious agent detection
Refer to: Molecular Diagnostic
Infectious Disease Testing
87560-Infectious agent detection
Refer to: Molecular Diagnostic
Infectious Disease Testing
87561-Infectious agent detection
Refer to: Molecular Diagnostic
Infectious Disease Testing
87562-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87580-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87581-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87582- Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87590-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing and NCD 210.10 Screening for STIs
87591-Infectious agent detection
Refer to: Molecular Diagnostic
Infectious Disease Testing
87592-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87623-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87624-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87625-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87631-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87632-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 60 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
87633-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87634-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87640-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87641-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87650-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87651-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87652-Infectious agent detection
by nucleic acid
Refer to: Molecular Diagnostic
Infectious Disease Testing
87653-Infectious agent detection
by nucleic acid
Refer to: Molecular Diagnostic
Infectious Disease Testing
87660-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87661-Infectious agent detection
by nucleic acid
Refer to: Molecular Diagnostic
Infectious Disease Testing
87662-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87797-Infectious agent detection
by nucleic acid
Refer to: Molecular Diagnostic
Infectious Disease Testing
87798-Infectious agent detection by nucleic acid
Refer to: Molecular Diagnostic Infectious Disease Testing
87799-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87800-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87801-Infectious agent detection
Refer to: Molecular Diagnostic Infectious Disease Testing
87802-Infectious agent detection X
87803-Infectious agent detection X
87804-Infectious agent detection X
87806-Infectious agent detection X
87807-Infectious agent detection X
87808-Infectious agent detection X
87809-Infectious agent detection X
87810-Infectious agent antigen detection by immunoassay
NCD 210.10 Screening for STIs
87850-Infectious agent antigen
detection by immunoassay
X
87880-Detection Infectious Agent by Immunoassay
X
87899-Infectious agent antigen detection by immunoassay
X
87900-Drug Sensitivity Genotype/Phenotype
X
87901-Infectious agent genotype analysis
Refer to: Molecular Diagnostic Infectious Disease Testing
87902-Infectious agent genotype analysis
Refer to: Molecular Diagnostic Infectious Disease Testing
Clinical Diagnostic Laboratory Services: CPT Codes Page 61 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
87903-Infectious agent genotype analysis
Refer to: Molecular Diagnostic Infectious Disease Testing
87904-Infectious agent genotype analysis
Refer to: Molecular Diagnostic Infectious Disease Testing
87905-Infectious agent enzymatic activity
X
87906-Infectious agent genotype analysis
Refer to: Molecular Diagnostic Infectious Disease Testing
87910-Infectious agent genotype analysis
Refer to: Molecular Diagnostic Infectious Disease Testing
87912-Infectious agent genotype analysis
Refer to: Molecular Diagnostic Infectious Disease Testing
87999-Unlisted microbiology
procedure
Refer to: Molecular Diagnostic
Infectious Disease Testing
88000-Autopsy Services Never Covered
88005-Autopsy Services Never Covered
88007-Autopsy Services Never Covered
88012-Autopsy Services Never Covered
88014-Autopsy Services Never Covered
88016-Autopsy Services Never Covered
88020-Autopsy Services Never Covered
88025-Autopsy Services Never Covered
88027-Autopsy Services Never Covered
88028-Autopsy Services Never Covered
88029-Autopsy Services Never Covered
88036-Autopsy Services Never Covered
88037-Autopsy Services Never Covered
88040-Autopsy Services Never Covered
88045-Autopsy Services Never Covered
88099-Autopsy Services Never Covered
88104-Cytopathology X
88106-Cytopathology X
88108-Cytopathology X
88112-Cytopathology X
88120-Cytopathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
88121-Cytopathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
88125-Cytopathology X
88130-Chromatin identification X
88140-Chromatin identification X
88141-Cytopathology
Special Considerations
88142-Cytopathology
Special
Considerations
88143-Cytopathology
Special Considerations
Clinical Diagnostic Laboratory Services: CPT Codes Page 62 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
88147-Cytopathology
Special Considerations
88148-Cytopathology
Special Considerations
88150-Cytopathology
Special Considerations
88152-Cytopathology
Special Considerations
88153-Cytopathology
Special Considerations
88155-Cytopathology
Special Considerations
88160-Cytopathology X
88161-Cytopathology X
88162-Cytopathology X
88164-Cytopathology
Special Considerations
88165-Cytopathology
Special
Considerations
88166-Cytopathology
Special Considerations
88167-Cytopathology
Special
Considerations
88172-Cytopathology X
88173-Cytopathology X
88174-Cytopathology
Special
Considerations
88175-Cytopathology
Special Considerations
88177-Cytopathology X
88182-Flow cytometry X
88184-Flow cytometry X
88185-Flow cytometry X
88187-Flow cytometry X
88188-Flow cytometry X
88189-Flow cytometry X
88199-Unlisted cytopathology procedure
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
88230-Tissue culture NCD 190.3 Cytogenetic Studies
88233-Tissue culture NCD 190.3 Cytogenetic Studies
88235-Tissue culture NCD 190.3 Cytogenetic Studies
88237-Tissue culture NCD 190.3 Cytogenetic Studies
88239-Tissue culture NCD 190.3 Cytogenetic Studies
88240-Cryopreservation NCD 190.3 Cytogenetic Studies
88241-Cryopreservation NCD 190.3 Cytogenetic Studies
88245-Chromosome analysis NCD 190.3 Cytogenetic Studies
88248-Chromosome analysis NCD 190.3 Cytogenetic Studies
88249-Chromosome analysis NCD 190.3 Cytogenetic Studies
Clinical Diagnostic Laboratory Services: CPT Codes Page 63 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
88261-Chromosome analysis NCD 190.3 Cytogenetic Studies
88262-Chromosome analysis NCD 190.3 Cytogenetic Studies
88263-Chromosome analysis NCD 190.3 Cytogenetic Studies
88264-Chromosome analysis NCD 190.3 Cytogenetic Studies
88267-Chromosome analysis NCD 190.3 Cytogenetic Studies
88269-Chromosome analysis NCD 190.3 Cytogenetic Studies
88271-Molecular cytogenetics NCD 190.3 Cytogenetic Studies
88272-Molecular cytogenetics NCD 190.3 Cytogenetic Studies
88273-Molecular cytogenetics NCD 190.3 Cytogenetic Studies
88274-Molecular cytogenetics NCD 190.3 Cytogenetic Studies
88275-Molecular cytogenetics NCD 190.3 Cytogenetic Studies
88280-Chromosome analysis NCD 190.3 Cytogenetic Studies
88283-Chromosome analysis NCD 190.3 Cytogenetic Studies
88285-Chromosome analysis NCD 190.3 Cytogenetic Studies
88289-Chromosome analysis NCD 190.3 Cytogenetic Studies
88291-Cytogenetics & molecular cytogenetics
NCD 190.3 Cytogenetic Studies
88299-Unlisted cytogenetic
study
NCD 190.3 Cytogenetic Studies
88300-Surgical Pathology No Restrictions
88302-Surgical Pathology No Restrictions
88304-Surgical Pathology No Restrictions
88305-Surgical Pathology No Restrictions
88307-Surgical Pathology No Restrictions
88309-Surgical Pathology No Restrictions
88311-Surgical Pathology X
88312-Surgical Pathology X
88313-Surgical Pathology X
88314-Surgical Pathology X
88319-Surgical Pathology X
88321-Surgical Pathology X
88323-Surgical Pathology X
88325-Surgical Pathology X
88329-Surgical Pathology X
88331-Surgical Pathology X
88332-Surgical Pathology X
88333-Surgical Pathology X
88334-Surgical Pathology X
88341-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
88342-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
88344-Surgical Pathology X
88346-Surgical Pathology X
Clinical Diagnostic Laboratory Services: CPT Codes Page 64 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
88348-Surgical Pathology X
88350-Surgical Pathology X
88355-Surgical Pathology X
88356-Surgical Pathology X
88358-Surgical Pathology X
88360-Surgical Pathology X
88361-Surgical Pathology X
88362-Surgical Pathology X
88363-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
88364-In situ hybridization X
88365-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
88366-In situ hybridization X
88367-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing
88368-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
88369-Surgical Pathology X
88371-Surgical Pathology X
88372-Surgical Pathology X
88373-Surgical Pathology X
88374-Surgical Pathology X
88375-Surgical Pathology X
88377-Surgical Pathology X
88380-Surgical Pathology X
88381-Surgical Pathology X
88387-Surgical Pathology X
88388-Surgical Pathology X
88399-Molecular Pathology
Refer to: Molecular Pathology/Molecular
Diagnostics/Genetic Testing
88720-Other Pathology
Procedures
X
88738-Other Pathology
Procedures
X
88740-Other Pathology Procedures
X
88741-Other Pathology
Procedures
X
88749-Other Pathology Procedures
X
89049-Other Pathology Procedures
X
89050-Other Pathology Procedures
X
Clinical Diagnostic Laboratory Services: CPT Codes Page 65 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
89051-Other Pathology Procedures
X
89055-Other Pathology Procedures
X
89060-Other Pathology Procedures
X
89125-Other Pathology Procedures
X
89160-Other Pathology Procedures
X
89190-Other Pathology Procedures
X
89220-Other Pathology
Procedures
X
89230-Sweat collection by
iontophoresis
NCD 190.5 Sweat Test
89240-Molecular Pathology
Refer to: Molecular Pathology/Molecular Diagnostics/Genetic Testing NCD 190.7 Human Tumor Stem
Cell Drug Sensitivity Assays
89250-Reproductive Medicine X
89251-Reproductive Medicine X
89253-Reproductive Medicine X
89254-Reproductive Medicine X
89255-Reproductive Medicine X
89257-Reproductive Medicine X
89258-Reproductive Medicine X
89259-Reproductive Medicine X
89260-Reproductive Medicine X
89261-Reproductive Medicine X
89264-Reproductive Medicine X
89268-Reproductive Medicine X
89272-Reproductive Medicine X
89280-Reproductive Medicine X
89281-Reproductive Medicine X
89290-Reproductive Medicine X
89291-Reproductive Medicine X
89300-Reproductive Medicine X
89310-Reproductive Medicine X
89320-Reproductive Medicine X
89321-Reproductive Medicine X
89322-Reproductive Medicine X
89325-Reproductive Medicine X
89329-Reproductive Medicine X
89330-Reproductive Medicine X
89331-Reproductive Medicine X
89335-Reproductive Medicine X
Clinical Diagnostic Laboratory Services: CPT Codes Page 66 of 66 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 02/12/2020
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
CPT Code
Medicare Covered
Preventive/
Screening
Lab NCD/MPG
(Payment Criteria Must Be Met)
Not Covered When
Submitted
with
Screening Diagnosis
Comments
89337-Reproductive Medicine X
89342-Reproductive Medicine X
89343-Reproductive Medicine X
89344-Reproductive Medicine X
89346-Reproductive Medicine X
89352-Reproductive Medicine X
89353-Reproductive Medicine X
89354-Reproductive Medicine X
89356-Reproductive Medicine X
89398-Molecular Pathology
Refer to: Molecular
Pathology/Molecular Diagnostics/Genetic Testing
CPT® is a registered trademark of the American Medical Association