MolDX: Predictive Classifiers for Early Stage Non-small Cell Lung Cancer

Molecular diagnostic tests (DNA/RNA/protein) as predictive classifiers for early-stage non-squamous NSCLC are considered reasonable and necessary when the patient has AJCC Eighth Edition Stage I or IIa non-squamous NSCLC, is fit for chemotherapy, adjuvant platinum-containing chemotherapy is being considered, and the test is ordered by the treating physician (typically a medical oncologist, surgeon, or radiation oncologist). The policy does not specify documentation requirements or frequency limits. Coverage is implicitly excluded when any of these criteria are not met (e.g., squamous histology, stages outside I/IIa, chemotherapy-ineligible patients, or tests ordered by non-treating clinicians).

"The test is a molecular diagnostic laboratory test (DNA, RNA, and/or protein) used as a predictive classifier for non-small cell lung cancer."

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