0083U
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- To receive a CSRA denial, the claim must include the appropriate CPT code for the specific in vitro chemosensitivity/chemoresistance assay.
- For a voluntarily issued ABN, append modifier GX to the claim.
- If a voluntary ABN is issued, append the GX modifier to the CPT code on the claim.
- To indicate a statutorily excluded service on the claim, append the GY modifier to the CPT code.
Key Coverage Criteria
- Coverage and medical necessity determinations for in vitro chemosensitivity and chemoresistance assays follow the Local Coverage Determination L34554.
- Beneficiary is being actively managed for bladder cancer.
- Use of EndoPredict or MammaPrint for breast cancer with 1–3 positive lymph nodes.
- Member has a diagnosis of ovarian cancer and is being considered for PARP inhibitor therapy.
- Prognostic genetic/algorithmic testing for stage I cutaneous melanoma to assess risk of recurrence.
- Adjuvant platinum-containing chemotherapy is being considered for the patient.
9 Active Policies
NORIDIAN-L37628 — In Vitro Chemosensitivity & Chemoresistance Assays
JF Part B
PALMETTO-L34554 — In Vitro Chemosensitivity & Chemoresistance Assays
JJ Part B
A56071 — Billing and Coding: In Vitro Chemosensitivity & Chemoresistance Assays
A56871 — Billing and Coding: In Vitro Chemosensitivity & Chemoresistance Assays
AMBETTER-CG-Onc-Algo-2025.1
Related Codes
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