Note: 1) This list of codes may not be all-inclusive.
2) Deleted codes and codes which are not effective at the time the service is rendered may not be eligible for reimbursement.
Covered when medically necessary: Tumor Markers
Marker Covered Indication(s) CPT®*/ HCPCS
Code
Code Description
AFP Primary hepatocellular cancer 82105 Alpha-fetoprotein; serum AFP in combination with b-HCG (beta- human chorionic gonadotropin)
Nonseminoma germ cell testicular cancer
Germ cell ovarian cancer Undiagnosed pelvic mass
85105
84702 84703 84704
Alpha-fetoprotein; serum
Gonadotropin, chorionic (hCG); quantitative Gonadotropin, chorionic (hCG); qualitative Gonadotropin, chorionic (hCG); free beta chain
B2M (beta2-
microglobulin)
Multiple myeloma 82232 Beta-2 microglobulin Bladder-tumor
associated antigen
Bladder cancer 86294 Immunoassay for tumor antigen, qualitative or semiquantitative (eg, bladder tumor
Marker Covered Indication(s) CPT®*/ HCPCS
Code
Code Description
(BTA) antigen)
Calcitonin Thyroid medullary carcinoma 82308 Calcitonin CA (cancer antigen) 15-3, CA 27.29, BR 27.29 or Truquant RIA
Metastatic breast cancer 86300 Immunoassay for tumor antigen, quantitative; CA 15-3 (27.29)
CA 19.9 Pancreatic Cancer 86301 Immunoassay for tumor antigen, quantitative;
CA 19-9 CA 125 Epithelial ovarian cancer
Endometrial cancer Undiagnosed pelvic mass
86304 Immunoassay for tumor antigen, quantitative; CA 125
CEA
(carcinoembryonic antigen)
Colorectal cancer Medullary thyroid cancer Metastatic breast cancer
82378 Carcinoembryonic antigen (CEA)
CgA (chromogranin A)
Neuroendocrine tumors (e.g., carcinoid tumors, neuroblastoma, and small cell lung cancer)
86316 Note: Covered as medically necessary when used to report the Chromogranin A (CgA)
Immunoassay for tumor antigen, other antigen, quantitative (eg, CA 50, 72-4, 549), each C-kit (CD-117 [cluster of differentiation-117]) Gastrointestinal stromal tumors 81404 88342
Molecular pathology procedure, Level 5 (eg, analysis of 2-5 exons by DNA sequence analysis, mutation scanning or
duplication/deletion variants of 6-10 exons, or characterization of a dynamic mutation disorder/triplet repeat by Southern blot analysis)
Immunohistochemistry (including tissue immunoperoxidase), each antibody ER/PR (estrogen receptors and progesterone receptors) Breast Cancer 88342 88360 88361
Immunohistochemistry (including tissue immunoperoxidase), each antibody Morphometric analysis, tumor
immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, each antibody; manual
Morphometric analysis, tumor
immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, each antibody, using computer-assisted technology.
Marker Covered Indication(s) CPT®*/ HCPCS Code Code Description 5-HIAA (5- hydrocyindoleasceti c acid)
Carcinoid tumors 83497 Hydroxyindolacetic acid, 5-(HIAA)
Gene expression classifier for thyroid nodule (i.e., Afirma® Thyroid FNA Analysis) Cytologically indeterminate thyroid nodule 81479 Note: Covered when medically necessary and used to report Gene expression classifier for thyroid nodule (i.e., Afirma® Thyroid FNA Analysis).
Unlisted molecular pathology procedure
HCG (human chorionic gonadotropin) Trophoblastic testicular cancer Trophoblastic ovarian cancer 84702 84703 84704
Gonadotropin, chorionic (hCG); quantitative Gonadotropin, chorionic (hCG); qualitative Gonadotropin, chorionic (hCG); free beta chain HER2 (human epidermal growth factor receptor 2) when performed by immunohistochemic al (IHC) and/or fluorescent in situ hybridization (FISH) ImmunoCyte™/yCyt e+™ Breast cancer 83950 88271 88342 88360 88361 Oncoprotein, HER-2/neu
Molecular cytogenetics; DNA probe, each (eg, FISH)
Immunohistochemistry (including tissue immunoperoxidase), each antibody Morphometric analysis, tumor
immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, each antibody; manual
Morphometric analysis, tumor
immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, each antibody; using computer-assisted technology.
MPO
(myeloperoxidase)
Acute myeloid leukemia 83876 Myeloperoxidase (MPO) Nuclear-Matrix
Protein (NMP22)
Bladder cancer 86386 Nuclear Matrix Protein 22 (NMP22), qualitative
NSE (neuron- specific enolase)
Small cell lung cancer 86316 Immunoassay for tumor antigen, other antigen, quantitative (eg CA 50, 72-4, 549), each
PSA (prostate- specific antigen)
Prostate cancer 84152
84153
Prostate specific antigen (PSA); complexed (direct measurement)
Marker Covered Indication(s) CPT®*/ HCPCS Code Code Description 84154 G0103
Prostate specific antigen (PSA); free Prostate cancer screening; prostate specific antigen test (PSA)
Thyroglobulin Differentiated thyroid cancer
84432 Thyroglobulin
Urovysion Bladder cancer 88120
88121
Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; using computer- assisted technology
Paraneoplastic (Onconeural) Antibodies (anti-Hu, anti-YO, antiCV2, anti-RI, anti-Ma2, anti-amphiphysin) Covered when medically necessary for the evaluation of neurological symptoms when the diagnosis remains uncertain following conventional work-up and an occult neoplasm is suspected:
CPT* Codes Description
83520 Immunoassay for analyte other than infectious agent antibody or infectious antigen; quantitative, not otherwise specified
84181 Western Blot, with interpretation and report, blood or other body fluid
84182 Western Blot, with interpretation and report, blood or other body fluid, immunological probe for band identification, each
Other Tumor Markers
Experimental/Investigational/Unproven/Not Covered for the screening, staging, diagnosis, monitoring and/or surveillance of cancer:
CPT* Codes Description
81287 MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme), methylation analysis (Code effective 01/01/2014)
81479† Unlisted molecular pathology procedure
81500 Oncology (ovarian), biochemical assays of two proteins (CA-125 and HE-4), utilizing serum, with menopausal status, algorithm reported as a risk score
81503 Oncology (ovarian), biochemical assays of five proteins (CA-125, apolipoprotein A1, beta-2 microglobulin, transferring, and pre-albumin), utilizing serum, algorithm reported as a risk score 81504 Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing
formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores (Code effective 01/01/2014)
81599† Unlisted multianalyte assay with algorithmic analysis 82387 Cathepsin-D
83520 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified
83951 Oncoprotein; des-gama-carboxy-prothrombin (DCP) 84275 Sialic acid
88358 Morphometric analysis; tumor (eg, DNA ploidy) Multiple/Varied
†
Note: Not covered when used to report any tumor marker indicated in this Coverage Policy as experimental, investigational/unproven.
Serum Marker Panels for Liver Disease
Experimental/Investigational/Unproven/Not Covered when used to report serum marker panels for the diagnosis or clinical management of liver disease:
CPT* Codes Description
82172 Apolipoprotein, each 82247 Bilirubin; total
82465 Cholesterol, serum or whole blood, total
82947 Glucose; quantitative, blood (except reagent strip) 82977 Glutamyltransferase, gamma (GGT)
83010 Haptoglobin; quantitative
83520 Immunoassay, analyte, quantitative; not otherwise specified 83883 Nephelometry, each analyte not elsewhere specified 84450 Transferase; aspartate amino (AST) (SGOT)
84460 Transferase; alanine amino (ALT) (SGPT) 84478 Triglycerides
84999 Unlisted chemistry procedure
0001M Infectious disease, HCV, six biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, and haptoglobin) utilizing serum, prognostic algorithm reported as a scores for fibrosis and necroinflammatory activity in liver
0002M Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and alcoholic steatohepatitis (ASH)
0003M Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and nonalcoholic steatohepatitis (NASH)
*Current Procedural Terminology (CPT®) ©2012 American Medical Association: Chicago, IL.