S3841 — Genetic testing for retinoblastoma
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
- Clinical documentation of the affected individual's cancer diagnosis when applicable.
- Documentation of clinical rationale showing the test is clinically warranted and appropriately applied.
- Documentation/evidence that analytic validity, clinical validity, and clinical utility of the panel were evaluated.
- Documentation (gene list or test report) demonstrating the panel does not include genes without known association to the disease in question.
Key Coverage Criteria
- Personal history of metastatic prostate cancer.
- Personal history of high- or very-high-risk group prostate cancer.
- Multiple primary breast cancers (diagnosed synchronously or metachronously).
- Personal history of breast cancer AND Ashkenazi Jewish ancestry.
- Personal history of breast cancer AND one or more close relatives with exocrine pancreatic cancer.
- First-degree relative with a confirmed diagnosis of Birt‑Hogg‑Dubé syndrome (BHDS).
4 Active Policies
AMBETTER-CG-Hered-CA-Suscep-2025.1 — Concert Genetic Testing: Hereditary Cancer Susceptibility
CARELON-hereditary-cancer-testing-2025-03-23-updated-2026-01-01-2 — Hereditary Cancer Testing
CARELON-genetic-testing-for-inherited-conditions-2024-06-30-updated-01-20-2025 — Genetic Testing for Inherited Conditions
REGENCE-GT20 — Genetic and Molecular Diagnostic Testing
Related Codes
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