89050
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
- No documentation requirements for coverage are specified because the tests are considered experimental/investigational and not covered.
- The policy and cited guideline language recommend that participation in clinical trials evaluating these technologies remains a priority; therefore, documentation supporting enrollment in an IRB-approved clinical trial may be required when tests are used in that research context (policy: "Because the in-vitro analytic strategy has potential importance, participation in clinical trials evaluating these technologies remains a priority").
Key Coverage Criteria
- Explicit technologies/procedures designated investigational (no covered indications listed): ChemoFx assay; differential staining cytotoxicity (DiSC) assay; fluorescence (Cytoprint) assay; human tumor cloning assay (HTCA); human tumor stem cell assay; methyl thiazolyl-diphenyl-tetrazolium bromide (MTT) assay; microculture kinetic (MiCK) apoptosis assay (also known as CorrectChemo); NexGen Cancer Cytotoxicity Assay; 3D Predict Glioma (Kiyatec Inc.); Reverse Phase Protein Array (Theralink).
- None. (No indications for which chemosensitivity assays are considered covered are stated in this policy.)
1 Active Policy
AETNA-CPB-0245 — Tumor Chemosensitivity Assays
Related Codes
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