87451
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
- Testing must be ordered and performed according to test manufacturer's intended indications for use (document manufacturer's intended use).
- Ordered by a qualified health care practitioner, practicing within the scope of their license and who is actively managing the individual's care (document ordering clinician and that they are actively managing care).
- Analytical validity of the testing method must be supported by published, peer-reviewed prospective evidence (document citations or evidence demonstrating analytical validity where applicable).
- Test must be FDA cleared or approved and/or performed in an appropriately credentialed and certified laboratory setting (document FDA clearance/approval or CLIA/credentialing).
Key Coverage Criteria
- If the test, condition or indication is addressed by another Cigna Coverage Policy, please use the more specific policy.
- A laboratory test or panel of tests that is required to prevent, evaluate, diagnose or treat an illness, injury, disease or its symptoms is considered medically necessary if ALL of the following criteria are met:
- the testing method for each single test or test in a panel is scientifically valid (i.e., analytical validity: accuracy, precision, sensitivity, specificity, reproducibility of results) based on published, peer-reviewed prospective evidence
- ordered and performed according to test manufacturer's intended indications for use
- ordered by a qualified health care practitioner, practicing within the scope of their license and who is actively managing the individual's care
- US Food and Drug Administration (FDA) cleared or approved and/or performed in an appropriately credentialed and certified laboratory setting
1 Active Policy
CIGNA-0604 — Laboratory Testing Services - (0604)
Related Codes
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