Molecular Pathology Procedures

Molecular pathology procedures (Tier 1 and Tier 2) are covered only when alternative definitive tests are unavailable or equivocal, a clinically valid test exists in peer‑reviewed literature, the assay is FDA‑approved or the lab documents analytical validity/clinical utility, and results directly impact patient management. Coverage is limited by once‑per‑lifetime rules for inherited-condition diagnostic testing, restrictions on panel scope to clinically necessary genes, exclusion of presymptomatic/risk‑only screening, and requirements for documentation and potential pre/postpayment review.

"Molecular pathology procedures (Tier 1 and Tier 2) are eligible for coverage only when alternative laboratory or clinical tests to definitively diagnose the disorder/identify the condition are unav..."

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