Billing and Coding: MolDX: PIK3CA Gene Tests

PIK3CA targeted gene sequencing is covered when used to detect PIK3CA mutations in HR-positive, HER2-negative advanced or metastatic breast cancer (postmenopausal women and men) to inform treatment with alpelisib after progression on endocrine therapy. Claims must include the appropriate CPT and diagnosis codes and specific claim-level identifiers (DEX Z-Code) submitted in the specified fields (SV101-7, SV202-7, NTE, Box 19, or Block 80) and testing relied upon for alpelisib eligibility should be an FDA-approved PIK3CA test; effective for dates of service on or after May 24, 2019.

"PIK3CA targeted gene sequencing is indicated to detect PIK3CA mutations in patients with hormone receptor (HR)-positive, HER2-negative, advanced or metastatic breast cancer (postmenopausal women an..."

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