Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Next Generation Sequencing Testing in Cancer

This policy defines coverage and billing rules for targeted tumor NGS panels and Comprehensive Genomic Profile (CGP) testing in cancer. Targeted panels that detect hotspot somatic alterations required for management are coverable and billed with specified CPTs (e.g., 81445/81450; 81457/81458 for MSI/CNV), while CGPs are coverable when they meet the comprehensive components and technical assessment and are billed with CPT 81459 or 81479 plus the approved DEX Z-Code. CGP coverage is limited to one test per surgical specimen, unit of service is one, and single-gene Tier 1/2 CPT codes must not be used for genes tested as part of a multiplex panel.

"Targeted tumor NGS panels are covered when they identify somatic alterations (SNVs, small INDELs, single-site CNVs, or gene fusions) at known hotspot regions required for cancer management, includi..."

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