
Optima Health Laboratory Testing Policies
Optima
Health has partnered with Avalon Healthcare Solutions for Laboratory Benefits
Management (LBM) in order to administer Avalon’s Routine Testing Management
(RTM), a post-service pre-payment clinical claim editing program and Genetic
Testing Management (GTM), a pre-service prior authorization program for genetic
testing. The laboratory testing policies for both the RTM and GTM program are
accessible through the links below. These policies have been modified for
Optima Health’s various products to align with government program policies,
rules, and/or state and federal contracts, but note that in case of conflict, the
government program policies, rules, and/or state and federal contracts will
take precedence.
Please
note that policies with an asterisk (*) are listed here for review purposes
only and are not currently being used to determine coverage. The effective dates
for these Policies has not been determined at this time, but will be shared at
least 60 day prior to their effective date.
DISCLAIMER: Application of coverage criteria is dependent
upon an individual’s benefit coverage at the time of the request. If there is a
conflict between this Policy and any relevant, applicable government policy
[e.g. Local Coverage Determinations (LCDs) or National Coverage Determinations
(NCDs) for Medicare] for a particular member, then the government policy will
be used to make the determination. For the most up-to-date Medicare policies
and coverage, please visit their search website http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx or
the manual website
- F2019: Flow Cytometry
- G2002: Cervical Cancer Screening
- G2005: Vitamin D Testing
- G2006: Hemoglobin A1c
- G2007: Prostate Biopsies
- G2008: Prostate Specific Antigen (PSA) Testing
- G2009: Preventive Screening in Adults
- G2011: Diagnostic Testing of Iron Homeostasis and Metabolism
- G2013: Testosterone Testing
- G2014: Vitamin B12 And Methylmalonic Acid Testing
- G2022: ANA and ENA Testing
- G2031: Allergen Testing
- G2035: Prenatal Screening *
- G2036: Hepatitis C
- G2042: Pediatric Preventive Screening
- G2043: Celiac Disease Testing
- G2044: Helicobacter pylori Testing
- G2045: Thyroid Disease Testing
- G2048: Biochemical Markers Of Alzheimer Disease and Dementia
- G2050: Cardiovascular Disease Risk Assessment *
- G2051: Bone Turnover Markers Testing
- G2054: Liquid Biopsy *
- G2055: Prenatal Screening for Fetal Aneuploidy *
- G2056: Diagnosis of Idiopathic Environmental Intolerance
- G2059: Epithelial Cell Cytology In Breast Cancer Risk Assessment
- G2060: Fecal Analysis in The Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing
- G2061: Fecal Calprotectin Testing
- G2063: Testing for Diagnosis of Active or Latent Tuberculosis
- G2098: Immune Cell Function Assay
- G2099: Intracellular Micronutrient Analysis
- G2100: In Vitro Chemoresistance And Chemosensitivity Assays
- G2105: Immunopharmacologic Monitoring of Therapeutic Serum Antibodies
- G2107: Measurement Of Thromboxane Metabolites For ASA Resistance
- G2110: Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
- G2113: Oral Screening Lesion Identification Systems and Genetic Screening
- G2115: Metabolite Markers For Thiopurines Testing
- G2119: Diagnostic Testing of Influenza
- G2120: Salivary Hormone Testing
- G2121: Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease
- G2123: Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases
- G2124: Serum Tumor Markers for Malignancies
- G2125: Urinary Tumor Markers for Bladder Cancer
- G2127: Vectra DA Blood Test for Rheumatoid Arthritis
- G2130: ST2 Assay for Chronic Heart Failure
- G2132: Erectile Dysfunction
- G2133: ZIKA Virus Risk Assessment
- G2138: Evaluation of Dry Eyes
- G2143: Lyme Disease
- G2148: Gene Test Hereditary Hearing Loss *
- G2149: Pathogen Panel Testing
- G2150: Cardiac Biomarkers for Myocardial Infarction
- G2151: Serum Testing for Evidence of Mild Traumatic Brain Injury *
- G2153: Pancreatic Enzyme Testing for Acute Pancreatitis
- G2154: Folate Testing
- G2155: General Inflammation Testing
- G2156: Urine Culture Testing for Bacteria
- G2157: Diagnostic Testing Of Common Sexually Transmitted Infections
- G2158: Testing for Mosquito- or Tick-Related Infections
- G2159: Streptococcus Testing
- G2164: Parathyroid Hormone, Phosphorous, Calcium, and Magnesium Testing
- G2173: Gamma-glutamyl Transferase
- M2003: BRCA *
- M2004: Lynch Syndrome *
- M2012: Genetic Testing for Hereditary Hemochromatosis *
- M2017: Genetic Testing for Cystic Fibrosis *
- M2020: Gene Expression Testing for Breast Cancer Prognosis *
- M2021: Pharmacogenetic Testing *
- M2024: Genetic Testing for Polyposis Syndromes *
- M2025: Genetic Testing for Inherited Cardiomyopathies and Channelopathies *
- M2026: KRAS NRAS and BRAF Mutation Analysis in Colorectal Cancer *
- M2027: BCR-ABL 1 Testing *
- M2028: Genetic Testing for FMR1 Mutations *
- M2029: Genetic Testing and GEP in Patients with Cutaneous Melanoma *
- M2030: Testing for Targeted Therapy of Non-Small-Cell Lung Cancer *
- M2032: Whole Genome and Whole Exome Sequencing *
- M2033: Chromosomal Microarray *
- M2037: Genetic Testing for Familial Cutaneous Malignant Melanoma *
- M2038: Genetic Testing for Familial Alzheimer Disease *
- M2039: Pre-Implantation Genetic Testing *
- M2041: Venous and Arterial Thrombosis Risk Testing *
- M2057: Diagnosis of Vaginitis including Multi-target PCR Testing
- M2058: Genetic Testing for Adolescent Idiopathic Scoliosis *
- M2062: Genetic Testing for Acute Myeloid Leukemia *
- M2065: Molecular Profiling for Cancers of Unknown Primary Origin *
- M2066: Genetic Cancer Susceptibility Using Next Generation Sequencing *
- M2067: Therapeutic Drug Monitoring for 5-Fluorouracil *
- M2068: Testing for Alpha1 Antitrypsin Deficiency *
- M2069: Genetic Testing For CADASIL Syndrome *
- M2070: Genetic Testing For CHARGE Syndrome *
- M2071: Genetic Testing and Genetic Expression Profiling in Patients with Uveal Melanoma *
- M2072: Genetic Testing for Diagnosis of Inherited Peripheral Neuropathies *
- M2074: Genetic Testing for Duchenne, Becker, Facioscapulohumeral, and Limb-Girdle Muscular Dystrophies *
- M2075: Genetic Testing for Epilepsy *
- M2077: Genetic Testing for Fanconi Anemia *
- M2078: Genetic Testing For Germline Mutations Of the RET Proto-Oncogene *
- M2079: Genetic Testing for Hereditary Pancreatitis *
- M2080: Genetic Testing for Lactase Insufficiency *
- M2081: Genetic Testing for Li-Fraumeni Syndrome *
- M2082: Genetic Testing for Lpa Variants for Aspirin Treatment and CVD Risk Assessment *
- M2083: Genetic Testing for Ophthalmologic Conditions *
- M2084: Genetic Testing for Mental Health Disorders *
- M2085: Genetic Testing of Mitochondrial Disorders *
- M2087: Genetic Testing for PTEN *
- M2088: Genetic Testing for Rett Syndrome *
- M2091: Transplant Rejection Testing *
- M2093: HIV Genotyping and Phenotyping *
- M2097: Identification of Microorganisms using Nucleic Acid Probes
- M2101: Mutation Analysis in Myeloproliferative Neoplasms *
- M2108: Molecular Markers in Fine Needle Aspirates of the Thyroid *
- M2109: Molecular Panel Testing of Cancers for Diagnosis Prognosis and Identification of Targeted Therapy *
- M2111: Multigene Expression Assay for Colon Cancer *
- M2112: Nerve Fiber Density Testing
- M2114: Pancreatic Cancer Risk Testing Using Molecular Classifier in Pancreatic Cyst Fluid *
- M2116: Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection
- M2126: Use Of Common Genetic Variants (Single Nucleotide Polymorphisms) To Predict Risk Of Non-Familial Breast Cancer *
- M2131: Genetic Testing for Alpha and Beta Thalassemia *
- M2134: Genetic Testing for Neurofibromatosis and Related Disorders *
- M2136: DNA Ploidy Cell Cycle Analysis
- M2137: Genetic Testing for Familial Hypercholesterolemia *
- M2139: Molecular Analysis for Gliomas *
- M2141: Testing of Homocysteine Metabolism-Related Conditions *
- M2144: Connective Tissue Disorders *
- M2145: General Genetic Testing Germline Disorders *
- M2146: General Genetic Testing, Somatic Disorders *
- M2160: Molecular Testing of Pulmonary Specimens *
- M2166: Gene Expression Profiling and Protein Biomarkers for Prostate Cancer *
- M2167: Genetic Testing For Neurodegenerative Disorders *
- M2168: Proteogenomic Testing of Individuals with Cancer *
- M2170: Red Blood Cell Molecular Testing *
- M2171: Esophageal Pathology Testing *
- M2172: Onychomycosis Testing
- M2175: Minimal Residual Disease (MRD) *
- M2176: Testing for Autism Spectrum Disorder and Developmental Delay *
- M2177: Fibromyalgia Testing *
- M2178: Microsatellite Instability and Tumor Mutational Burden Testing *
- P2018: Immunohistochemistry
- R2162: Avalon Laboratory Procedures Reimbursement Policy
- SHP Medical 286 Exhaled Breath Condensate (EBC pH)
- SHP Medical 287 Anti-Phospholipid Antibody Testing
- SHP Medical 303 Apixaban (Eliquis) Drug Level
- SHP Medical 304 Galectin 3 (LGALS3)
- SHP Medical 307 Amnisure
- T2015: Prescription Medication and Illicit Drug Testing in the Outpatient Setting