0406U
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation confirming absence of metastatic disease.
- Cyst fluid CEA laboratory result (quantitative value).
- Pathology report documenting tumor ER-positive status
- Pathology report documenting tumor HER2-negative status
- Documentation of tumor histology specifying ductal/NST, lobular, mixed, or micropapillary
Key Coverage Criteria
- 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.
- Proteogenomic testing (combined DNA with RNA and/or protein analysis) for diagnostic and prognostic evaluation in various cancers and to identify potential treatment options and possible treatment resistance.
2 Active Policies
AMBETTER-CG-Onc-Algo-2025.1 — Concert Genetic Oncology: Algorithmic Testing
REGENCE-LAB73 — Molecular Testing in the Management of Pulmonary Nodules
Related Codes
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