81455
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- For services requiring a referring/ordering physician, the claim must report the referring/ordering physician's name and NPI.
- Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the genomic sequencing service was performed.
- Documentation should support that the panel's biomarkers meet Medicare coverage criteria (for example, NCCN Biomarkers Compendium Evidence Category I or 2A) and demonstrate associated clinical utility.
- Laboratories and clinicians including non‑NCCN genes in panels are advised to adhere to regulatory and institutional oversight mechanisms to document clinical validity and utility.
Key Coverage Criteria
- Targeted genomic sequence analysis panels for hematolymphoid neoplasms (including acute myelogenous leukemia, myelodysplastic syndromes, and myeloproliferative neoplasms) are covered when the panel contains at least 5 gene tests for molecular biomarkers that meet Medicare coverage criteria (for example, NCCN Biomarkers Compendium Evidence Category I or 2A) and are consistent with NCCN recommendations.
- Targeted genomic sequence analysis panels with 5–50 genes (CPT 81450 or 81451) or 51 or more genes (CPT 81455 or 81456) are represented by these CPT codes and may be used when the panel meets the minimum 5-gene and evidence requirements above.
- Minimal residual disease (MRD) testing in myelodysplastic syndromes (MDS) for single-gene tests may be covered when the test is medically reasonable and necessary for the individual patient's care.
- Coverage is allowed for targeted genomic sequence analysis panels for treatment of solid organ neoplasms when the panel is a DNA analysis panel containing at least 5 gene tests for molecular biomarkers that meet Medicare coverage criteria.
- Coverage is allowed when the genomic testing is expected to influence the treatment of the condition (i.e., documentation supports that test results will affect clinical management of the solid organ neoplasm).
- Genomic testing of acquired conditions such as malignancies, including separate malignancies developing at different times, is permitted when medically reasonable and necessary to assess response or other clinically relevant criteria.
20 Active Policies
L36807 — MolDX: Molecular Diagnostic Tests (MDT)
J05
A57772 — Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)
J05
A56793 — Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases
J06
A56867 — Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms
J06
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.