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

This policy defines coverage and billing requirements for tumor-based NGS testing: targeted tumor panels are covered for detecting hotspot somatic alterations that directly inform cancer management, while Comprehensive Genomic Profile (CGP) testing is covered when broader genomic characterization is needed to guide therapy, identify mechanisms (e.g., MSI, TMB), or locate clinical trials. Providers must report the approved DEX Z-Code® and appropriate CPT codes (commonly 81445/81450 for targeted panels; 81459 or 81479 for CGP or NOC scenarios), follow unit-of-service rules (UOS=1), and note that CGP coverage is limited to one test per surgical specimen and precludes further molecular testing on that specimen.

"Targeted tumor panels are covered when used to identify somatic alterations in defined gene regions ('hotspots') that inform cancer management (diagnosis, selection of targeted therapies, or essent..."