New Codes Requiring Preauthorization
The listing of a code does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply
Code Effective Date: November 6, 2022 Johns Hopkins Advantage MD
| Procedure Codes | Effective Date | Procedure Description | Advantage MD Prior Auth YES/NO/NA |
|---|---|---|---|
| 0332U EpiSwitch® CiRT Checkpoint-inhibitor Response Test |
11/6/2022 | Oncology (pan-tumor), genetic profiling of 8 DNA-regulatory (epigenetic) markers by quantitative polymerase chain reaction (qPCR), whole blood, reported as a high or low probability of responding to immune checkpoint–inhibitor therapy |
YES
PA per eviCore list
|
| 0333U HelioLiver™ Test, Fulgent Genetics |
11/6/2022 | Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in high-risk patients, analysis of methylation patterns on circulating cell-free DNA(cfDNA) plus measurement of serum of AFP/AFP-L3 and oncoprotein des-gamma-carboxy prothrombin (DCP), algorithm reported as normal or abnormal result |
YES
PA per eviCore list
|
| 0334U Guardant360 TissueNext™ |
11/6/2022 | Oncology (solid organ), targeted genomic sequence analysis, formalin-fixed paraffin embedded (FFPE) tumor tissue, DNA analysis, 84 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden |
YES
PA per eviCore list
|
| 0335U IriSight™ Prenatal Analysis – Proband Variantyx Inc |
11/6/2022 | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile element insertions, uniparental disomy (UPD), inversions, aneuploidy, mitochondrial genome sequence analysis with heteroplasmy and large deletions, short tandem repeat (STR) gene expansions, fetal sample, identification and categorization of genetic variants |
YES
PA per eviCore list
|
| 0336U IriSight™ Prenatal Analysis – Comparator Variantyx Inc |
11/6/2022 | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile element insertions, uniparental disomy (UPD), inversions, aneuploidy, mitochondrial genome sequence analysis with heteroplasmy and large deletions, short tandem repeat (STR) gene expansions, blood or saliva, identification and categorization of genetic variants, each comparator genome (eg, parent) |
YES
PA per eviCore list
|
| 0339U SelectMDx® for Prostate Cancer MDxHealth®, Inc |
11/6/2022 | Oncology (prostate), mRNA expression profiling of HOXC6 and DLX1, reverse transcription polymerase chain reaction (RT-PCR), first-void urine following digital rectal examination, algorithm reported as probability of high-grade cancer |
YES
PA per eviCore list
|
| 0340U Signatera™, Natera, Inc |
11/6/2022 | Oncology (pan-cancer), analysis of minimal residual disease (MRD) from plasma, with assays personalized to each patient based on prior next-generation sequencing of the patient’s tumor and germline DNA, reported as absence or presence of MRD, with disease-burden correlation, if appropriate |
YES
PA per eviCore list
|
| 0341U Single Cell Prenatal Diagnosis (SCPD) Test, Luna Genetics |
11/6/2022 | Fetal aneuploidy DNA sequencing comparative analysis, fetal DNA from products of conception, reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplication, mosaicism, and segmental aneuploid |
YES
PA per eviCore list
|
| 0343U miR Sentinel™ Prostate Cancer Test, miR Scientific, LLC |
11/6/2022 | Oncology (prostate), exosome-based analysis of 442 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chainreaction (RT-qPCR), urine, reported as molecular evidence of no-, low-, intermediate- or high-risk of prostate cancer |
YES
PA per eviCore list
|
| 0345U GeneSight® Psychotropic, Assurex Health, Inc, Myriad Genetics, Inc |
11/6/2022 | Psychiatry (eg, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6 |
YES
PA per eviCore list
|
| 0347U RightMed® PGx16 Test, OneOme®, LLC |
11/6/2022 |
Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 16 gene report, with variant analysis and reported phenotypes
Best crosswalk code 81479- Unlisted molecular pathology procedure
|
YES
PA per eviCore list
|
| 0348U RightMed® Comprehensive Test Exclude F2 and F5 OneOme®, LLC |
11/6/2022 | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 25 gene report, with variant analysis and reported phenotypes |
YES
PA per eviCore list
|
| 0349U RightMed® Comprehensive Test, OneOme®, OneOme®, LLC |
11/6/2022 | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis including reported phenotypes and impacted gene-drug interactions |
YES
PA per eviCore list
|
| 0350U RightMed® Gene Report OneOme®, OneOme®, LLC |
11/6/2022 | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes |
YES
PA per eviCore list
|