MOLECULAR PATHOLOGY/GENETIC TESTING REPORTED WITH …€¦ · Molecular Pathology/Genetic Testing Reported with Unlisted Codes Page 3 of 28 UnitedHealthcare Medicare Advantage Policy

Molecular Pathology/Genetic Testing Reported with Unlisted Codes Page 1 of 28

UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/08/2020

Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc.

MOLECULAR PATHOLOGY/GENETIC TESTING REPORTED WITH UNLISTED CODES

Guideline Number: MPG383.01 Approval Date: April 8, 2020

Table of Contents Page

POLICY SUMMARY .................................................... 1 APPLICABLE CODES ................................................. 6 QUESTIONS AND ANSWERS ...................................... 7 PURPOSE ................................................................ 7 REFERENCES ........................................................... 7 GUIDELINE HISTORY/REVISION INFORMATION .......... 27 TERMS AND CONDITIONS ....................................... 28

POLICY SUMMARY

Overview When reporting the service performed, providers should select the specific code that accurately identifies the service

performed. However, some services may not have a specific code; therefore, when reporting for these services, unlisted codes are designated. Unlisted codes provide the means of reporting and tracking services until a more specific code is established. If no such specific code exists, reporting the service using the appropriate unlisted service

code would be appropriate. The service should be adequately documented in the medical record. Unlisted codes should be reported only if no other specific codes adequately describe the procedure or service. When reporting a laboratory tests using an unlisted code, the specific name of the laboratory test(s) and/or a short

descriptor of the test(s) must be included. Guidelines

Covered Indications Specific diagnosis criteria for covered services can be found in the Applicable Codes section.

For CPT Code 81479 Biomarkers for Oncology • MyPRS Genetic Expression Profile Testing

Myeloma Gene Expression Profile (MyPRS) (PROG) isolates plasma cells from myeloma patients, extracts DNA,

which is then subjected to MicroArray testing and application of validated software programs to identifying patterns of genetic abnormalities. Seventy highly predictive genes have been identified and correlated to myeloma early relapse. MyPRS gives a predictive risk signature as high-risk or low-risk at this time. A high-risk score

predicts a less than 20% three-year complete remission where as a low-risk predicts a five-year complete remission of greater than 60%. The predictive value for the stratification of therapeutic interventions allows these patients to be treated in a more personalized manner based on their own genetic profile.

This test is considered reasonable and necessary only after the initial diagnosis of multiple myeloma has been

made and will be available to be used in the stratification of therapeutic interventions. It would be inappropriate to use this test as a diagnostic tool or as a monitoring device of ongoing therapy. Other testing is available for this

function.

Related Medicare Advantage Policy Guidelines

• Biomarkers in Cardiovascular Risk Assessment

• Clinical Diagnostic Laboratory Services

• Molecular Pathology/Molecular Diagnostics/Genetic

Testing

Related Medicare Advantage Reimbursement Policies

• Clinical Laboratory Improvement Amendments (CLIA) ID Requirement Policy, Professional

• Laboratory Services Policy, Professional

Related Medicare Advantage Coverage Summaries

• Genetic Testing

• Laboratory Tests and Services

UnitedHealthcare® Medicare Advantage

Policy Guideline

Terms and Conditions

See Purpose

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/b/biomarkers-cardiovascular-risk-assessment.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/c/clinical-diagnostic-laboratory-services.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/m/molecular-pathology-diagnostics-genetic-testing.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/m/molecular-pathology-diagnostics-genetic-testing.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-reimbursement/MEDADV-CLIA-ID-Requirement-Policy.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-reimbursement/MEDADV-CLIA-ID-Requirement-Policy.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-reimbursement/MEDADV-Laboratory-Services-Policy.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/genetic-testing.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/genetic-testing.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/laboratory-tests-services.pdf




• Rosetta Cancer Origin Test™ Molecular testing, using the Rosetta Cancer Origin Test™ (PROG), is considered reasonable and necessary in the

pathologic diagnoses of CUP when a conventional surgical pathology/imaging work-up is unable to identify a primary neoplastic site. Other applications of this technology are considered not reasonable and necessary and are considered investigational in the use of diagnosis of specific tumor types such as NSCLC and renal cancers.

• RosettaGX Reveal thyroid MicroRNA test, is an assay used for the classification of indeterminate thyroid nodules

• Uveal Melanoma GNA11 • CIMP • PTEN

• AKT1 • RB1 • MLL/AF4

• DEK/CAN • TET2 • CALR • CSF3R

• TSC2 • FGFR1 • MTOR

Pathfinder TG® PathfinderTG® is considered medically reasonable and necessary when selectively used as an occasional second-line

diagnostic supplement: • only where there remains clinical uncertainty as to either the current malignancy or the possible malignant

potential of the pancreatic cyst based upon a comprehensive first-line evaluation; and • a decision regarding treatment (e.g., surgery) has not already been made based on existing information.

AlloSure® Donor-Derived Cell-Free DNA Test The AlloSure assay is covered only when the following clinical conditions are met:

• Renal allograft recipients > 18 years • Physician-assessed pretest need to further assess patient for the probability of active renal allograft rejection • At least 2 weeks post-transplant

BCR-ABL Breakpoint testing for BCR-ABL1 is commonly performed as a combination or panel of tests (major, minor and other

breakpoints). To report multiple tests assigned a single ID, submit CPT code 81479.

81479 should also be used to report BCR-ABL translocation analysis by Next Generation Sequencing (NGS). ClonoSEQ® Assay

Minimal Residual Disease (MRD) refers to a measure of cancer burden that remains in a person during and following treatment. Clinical practice guidelines in a number of hematological malignancies recommend MRD testing and recognize MRD status as a reliable indicator of clinical outcome and response to therapy, which is currently

recommended in the course of treatment of patients with acute lymphoblastic leukemia (ALL) or multiple myeloma, and chronic lymphocytic leukemia (CLL). ClonoSEQ® Assay testing is reasonable and necessary when performed on bone marrow specimens in patients with B-

Cell acute lymphoblastic leukemia (ALL), multiple myeloma or chronic lymphocytic leukemia (CLL). A single episode of testing using clonoSEQ® in these patients will be covered. For a patient with ALL, multiple myeloma or CLL in whom clonoSEQ® is being used according to its FDA cleared indications and clinical guidelines, it is anticipated that an

episode of testing will typically require a baseline assay and 3 follow-up assays. This service should be billed at the start of the episode of testing. One test per member per cancer diagnosis may be covered.

Cobas® EGFR Mutation Test cobas EGFR Mutation Test for the detection of epidermal growth factor receptor (EGFR) gene for non-small cell lung cancer (NSCLC) tumor tissue. The test is intended to be used to help select patients with NSCLC for whom Tarceva® (erlotinib), an EGFR tyrosine kinase inhibitor (TKI), is indicated.

Therascreen® EGFR RGQ PCR Kit Therascreen EGFR RGQ PCR kit is covered for the detection of the epidermal growth factor receptor (EGFR) gene from

non-small cell lung cancer (NSCLC) tumor tissue. The test is intended to be used to select patients with NSCLC for

whom GILOTRIF™ (afatinib), an EGFR tyrosine kinase inhibitor (TKI), is indicated.




Envisia Genomic Classifier Limited coverage is allowed for the Envisia Genomic Classifier (Veracyte, Inc., South San Francisco, CA), a tissue

based multi-analyte assay with algorithm analysis test (hereafter called Envisia) for interstitial lung disease (ILD) patients who are suspected of idiopathic pulmonary fibrosis (IPF) and who do not have a definitive usual interstitial pneumonia (UIP) pattern by high resolution computed tomography (HRCT) or other known cause of ILD. IPF suspicion increases significantly in patients greater than 60 years of age when HRCT is not definitive, and comorbidities in this

population make clinicians reluctant to perform surgical lung biopsy to obtain a diagnosis due to significant procedure morbidity and mortality. Envisia testing is performed on less-invasive bronchoscopy transbronchial biopsy samples and is intended to provide a categorical UIP or Non-UIP result that along with clinical and radiographic information

may guide treatment without the need or risk of surgical lung biopsy. Criteria for Coverage

The Envisia classifier is reasonable and necessary when all of the following conditions are met: • That are healthy enough to undergo a bronchoscopy with transbronchial biopsies, and • High-resolution CT scan of the chest (defined by high kernel ~1mm axial reconstructions, including both

inspiratory and expiratory imaging) showing one of the following:

o A Probable UIP pattern or o An Indeterminate for UIP

• Exclusion of autoimmune disease by clinical evaluation and serologic testing, including, when indicated, an

evaluation by a rheumatologist • Absence of a definitive occupational, environmental, medication-related, or other cause of the patient’s lung

disease

GeneSight ® Assay Limited coverage is allowed for the GeneSight® Psychotropic (AssureRx Health, Inc, Mason, OH) gene panel. GeneSight® testing may only be ordered by licensed psychiatrists or neuropsychiatrists contemplating an alteration in

neuropsychiatric medication for patients diagnosed with major depressive disorder (MDD) who are suffering with refractory moderate to severe depression (based upon DSM-V criteria) after at least one prior neuropsychiatric medication failure.

A provider may have primary boards in internal medicine or neurology and also have boards in psychiatry or neuropsychiatry and the provider has a designated specialty in as IM/neurology. UnitedHealthcare allows the

GeneSight test to be ordered, when medically necessary, by these providers. A KX modifier must be used when reporting the Genesight panel attesting that the ordering physician has psychiatry or neuropsychiatry boards.

Guardant360®

Limited coverage is allowed for Guardant360® (Guardant Health, Redwood City, CA), a plasma-based comprehensive somatic genomic profiling test (CGP) for patients with Stage IIIB/IV non-small cell lung cancer (NSCLC):

• At diagnosis-Untreated Patient o When results for EGFR single nucleotide variants (SNVs) and (insertions and deletions (indels);

rearrangements in ALK and ROS1; and SNVs for BRAF are not available AND when tissue-based CGP is

infeasible (i.e., quantity not sufficient for tissue-based CGP or invasive biopsy is medically contraindicated), or

• At progression-Treated Patient o For patients progressing on or after chemotherapy or immunotherapy who have never been tested for EGFR

SNVs and indels; rearrangements in ALK and ROS1; and SNVs for BRAFs, and for whom tissue-based CGP is infeasible (i.e., quantity not sufficient for tissue-based CGP from original biopsy); OR

o For patients progressing on any tyrosine kinase inhibitors (TKIs).

Limited coverage is allowed for next-generation sequencing (NGS) assays performed on solid tumor cell-free DNA in plasma (liquid biopsies).

Guardant360® is covered only when all of the following conditions are met: • Patient has been diagnosed with a recurrent, relapsed, refractory, metastatic, or advanced solid tumor that did

not originate from the central nervous system. Patients who would meet all of the indications on the FDA label for

larotrectinib if they are found to have an NTRK mutation may be considered to have advanced cancer, and • Patient has not previously been tested with the Guardant360® test for the same primary cancer. For a patient who

has been tested previously using Guardant360® for cancer, that patient may not be tested again unless he or she

has a new primary cancer diagnosis. In a patient with previously tested primary cancer, who has evidence of new

malignant growth, that growth may be considered to be a different primary cancer if it does not originate from the same cell line or it is physiologically different enough that it responds differently to treatment than the previously

tested cancer, and




• Patient is untreated for the primary cancer being tested, or the patient is not responding to treatment (e.g., progression or new lesions on treatment), and

• The patient has decided to seek further cancer treatment with the following conditions: o The patient is a candidate for further treatment with a drug that is either FDA-approved for that patient’s

cancer, or has an NCCN 1 or NCCN 2A recommendation for that patient’s cancer, and o The FDA-approved indication or NCCN recommendation is based upon information about the presence or

absence of a genetic biomarker tested for in the Guardant360® assay, and • Tissue-based, CGP is infeasible (e.g., quantity not sufficient for tissue-based CGP or invasive biopsy is medically

contraindicated) or specifically in NSLC Tissue-based CGP has shown no actionable mutations.

Note: For covered diagnoses, see NGS for Solid Tumors in Molecular Pathology/Genetic Testing Reported with Unlisted Codes: ICD-10 Diagnosis Codes.

HERmark® Assay Limited coverage is allowed for the HERmark® test, it has been determined that the test meets criteria for analytical and clinical validity, and clinical utility.

InVisionFirst, Liquid Biopsy Limited coverage is allowed for InVisionFirstTM-Lung (Inivata, Research Triangle Park, NC) (hereafter InVision) a plasma-based, somatic comprehensive genomic profiling test (CGP) for patients with advanced (Stage IIIB/IV) non-

small cell lung cancer (NSCLC):

• At diagnosis and untreated o When results for EGFR single nucleotide variants (SNVs) and insertions and deletions (indels); rearrangements

in ALK and ROS1; and SNVs for BRAF are not available and

o When tissue-based CGP is infeasible [i.e., quantity not sufficient (QNS) for tissue-based CGP or invasive biopsy is medically contraindicated],

or

• At progression o For patients progressing on or after chemotherapy or immunotherapy who have not been tested for EGFR

SNVs and indels; rearrangements in ALK and ROS1; and SNVs for BRAF, and for whom tissue-based CGP is infeasible;

o For patients progressing on EGFR tyrosine kinase inhibitors (TKIs). Microsatellite Instability-High (MSI-H) and Mismatch Repair Deficient (dMMR) Biomarker The use of Keytruda for treatment of patients with unresectable or metastatic solid tumors having either microsatellite

instability-high (MSI-H) or mismatch repair deficient (dMMR) biomarkers. Keytruda, a human PD-1 blocking antibody, is indicated for the treatment of metastatic melanoma, non-small cell lung cancer, recurrent or metastatic head and neck squamous cancer, advanced/metastatic urothelial cancer and classical Hodgkin’s lymphoma.

This contractor will allow one of the following:

• dMMR by immunohistochemistry (IHC), or

• MSI by PCR, or

• Multi-gene NGS panel inclusive of MSI microsatellite loci, and MLH1, MSH2, MSH6 and PMS2 genes

Testing by one of the above methodologies is reasonable and necessary if testing for dMMR or MSI has not previously been performed on the patient’s tumor sample. A multi-gene NGS panel inclusive of MSI microsatellite loci and MLH1, MSH2, MSH6 and PMS2 gene is reasonable and necessary. A multi-gene NGS panel and separate MSI by PCR will be

denied as not reasonable and necessary. If testing is performed by NGS, the test must be a properly designed and appropriately validated assay demonstrating 95% concordance to the reference method (MSI by PCR). • To report a dMMR or MSI service, reference specific CPT codes • To report by NGS, use CPT code 81479.

Oncotype DX AR-V7 Nucleus Detect Limited coverage is allowed for the Oncotype DX AR-V7 Nucleus Detect to help determine which patients with

metastatic castrate resistant prostate cancer may benefit from androgen receptor signaling inhibitor therapy and which may benefit from chemotherapy.

Percepta© Bronchial Genomic Classifier Limited coverage is allowed for the Percepta Bronchial Genomic Classifier (Veracyte, Inc., South San Francisco, CA) to identify patients with clinical low- or intermediate-risk of malignancy, after a non-diagnostic bronchoscopy, who may be followed with CT surveillance in lieu of further invasive biopsies or surgery.

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/attachments/medadv/molecular-pathology-genetic-testing-unlisted-dx-codes.pdf





ProMark Risk Score Limited coverage is allowed for the ProMark (Metamark Genetics) to help determine which patients with early stage,

needle biopsy proven prostate cancer can be conservatively managed rather than treated with definitive surgery or radiation therapy. Prospera™

Limited coverage is allowed for the Prospera™ donor-derived cell-free DNA test (dd-cfDNA) (Natera, Inc., San Carlos, CA) to supplement the evaluation and management of kidney injury and active rejection (AR) in patients who have undergone renal transplantation. It can inform decision making along with standard clinical assessments.

Criteria for Coverage

The Prospera™ assay is covered only when the following conditions are met:

• The patient has a renal allograft

• Physician-assessed pretest need to further evaluate patient for the probability of active renal allograft rejection Targeted and Comprehensive Genomic Profile Next Generation Sequencing (NGS) Testing

Targeted Next-Generation Sequencing (NGS) panels are defined as tests that identify somatic alterations known to occur in certain regions (i.e., 'hotspots') within specific genes of interest for cancer management (i.e., diagnosis, selection of molecularly targeted therapies, prognosis in a context where prognostic classification is essential for

treatment selection). Generally, these NGS panels can detect single nucleotide variants (SNVs) and small insertions or deletions (INDELs) within these regions. These alterations typically represent response or lack of response to corresponding targeted cancer therapies. The hotspot test should include relevant regions in the genes required for companion diagnostic testing and/or known to be necessary for proper patient management.

CGP refers to NGS-based molecular assays that provide additional insight beyond individual gene hotspots; these assays seek to describe the genomic makeup of a tumor and can help identify underlying mechanisms of disease to

guide clinical decision making. These tests include not only mutations in individual relevant genes, but also patterns of mutations across related genes in established cancer pathways and often include an assessment of overall mutational burden. These tests typically involve sequencing of entire exonic regions of genes of interest (within a comprehensive

gene panel or whole exome sequencing) and may also include selected intronic regions. CGP can detect multiple types of molecular alterations (i.e., SNVs, small and large INDELs, copy number alterations (CNAs), structural variants (SVs), and splice-site variants) in a single assay. Patterns of mutations seen across multiple genes may be used to infer clinically relevant etiologies, such as DNA mismatch repair deficiency and microsatellite instability, and total

mutational load/burden (TMB) may be determined. CGP testing may also include RNA sequencing to detect structural

variations, such as translocations or large deletions, and to detect functional splicing mutations. CGP is not defined as a targeted panel by MolDX.

A targeted NGS panel which includes 1-4 genes would be appropriately reported with CPT code 81479, for other targeted NGS gene panel services for somatic variant detection more specific CPT codes exist.

CGP testing is not defined as a targeted panel, and it is a test not currently described by any existing CPT code. Therefore, to report a CGP service use CPT code 81479. Coverage of CGP is limited to one test per surgical specimen and precludes the use of any other molecular testing on that specimen.

For NGS-based tests that do not fit under the above definitions of “targeted” or “Comprehensive” panels, reporting CPT code 81479 is appropriate.

TruGraf® Blood Gene Expression Test Limited coverage is allowed for the TruGraf®Blood Gene Expression Test (Transplant Genomics Inc., Mansfield, MA) as

an alternative to surveillance biopsies in kidney transplant recipients, in conjunction with standard clinical assessment. The TruGraf® test is covered only when all of the following clinical conditions are met:

• Patient is at least 18 years of age,

• Recipient of a primary or subsequent deceased-donor or living-donor kidney transplantation.

• Stable serum creatinine (current serum creatinine <2.3 mg/dl, <20% increase compared to the average of the previous 3 serum creatinine levels).

• Kidney transplant patients who are more than 90 days post-transplant

• Patient is being managed in a facility that utilizes surveillance biopsies

TruGraf® should not be used on patients who are:

• Recipients of a combined organ transplantation with an extra-renal organ and/or islet cell transplant.

• Recipients of previous non-renal solid organ and/or islet cell transplantation.




• Infected with HIV.

• Patients with BK nephropathy.

• Patients that have nephrotic proteinuria (urine protein >3 gm/day). For CPT Code 81599

DecisionDx-Melanoma The DecisionDx-Melanoma test is covered only when the following clinical conditions are met: • Patients diagnosed with clinical stage, sentinel lymph node biopsy (SLNB) eligible, T1 and T2 cutaneous melanoma

tumors (as defined in AJCC Staging Manual v8, 2017) with clinically negative sentinel node basins who are being

considered for SLNB to determine eligibility for adjuvant therapy. (Per current NCCN and ASCO guidelines, SLNB eligible patients are defined as:

o Patients with T1a tumors: ▪ in whom there is significant uncertainty about the adequacy of microstaging (positive deep margin), or ▪ with Breslow depth <0.8 mm and with other adverse features (e.g., very high mitotic index [≥2/mm2],

lymphovascular invasion, or a combination of these factors)

o Patients with T1b tumors (≥0.8 mm or < 0.8 mm with ulceration) o Patients with T2 tumors

For CPT Code 84999 Avise PG Assay Limited coverage is allowed for The Avise PG Assay, developed to support dose optimization and therapeutic

decision making for patients diagnosed with rheumatoid arthritis (RA) on methotrexate ("MTX"). Non-Covered Indications The test descriptions under the following unlisted codes are appropriate to be reported with the unlisted code however

there is no coverage for these services. For CPT Code 81479 SelectMDx, MiPS

• 4q25-AF Risk Genotype Test • 9p21 Genotype Test • Asparoacyclase 2 Deficiency (ASPA) Test

• ATP7B Gene Test • BluePrint® Test • CFTR Gene Analysis

• CHD7 Gene Analysis

• CYP2B6 Test • CYP gene panels (testing for more than 1 CYP gene on same date of service) • ENG and/or ACVRL1 genetic testing and panels of tests that include ENG/ACVRL1

• HAX1 gene sequencing and panels of tests that include the HAX1 gene • Serotonin Transporter genotyping (HTTLPR)/ HTTLPR Gene Testing • KIF6 genotype test

• LPA-Aspirin genotype test • LPA-Intron 25 genotype test • MECP2 genetic testing and panels of tests that include a MECP2 gene test • Mitochondrial Nuclear Gene Test

• NSD1 gene testing and tests that include one or more of NSD1 analysis • PAX6 Gene Sequencing • Prometheus IBD sgi Diagnostic

• PTCH1 Gene Test • RPS19 Gene Tests • SULT4A1 Genetic Testing and panels of tests that include the SULT4A1 gene

• TERC Gene Test • VEGFR2 testing and panels of tests that include the VEGFR2 receptor • Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) Testing

For CPT Code 84999

• know error® DNA Specimen Provenance Assay

• myPAP™ DNA test APPLICABLE CODES

The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline 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 plan 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.

CPT Code Description

81479 Unlisted molecular pathology procedure

81599 Unlisted multianalyte assay with algorithmic analysis

84999 Unlisted chemistry procedure

85999 Unlisted hematology and coagulation procedure

86849 Unlisted immunology procedure

CPT® is a registered trademark of the American Medical Association

Modifier Description

KX Requirements specified in the medical policy have been met

ICD-10 Diagnosis Codes

Molecular Pathology/Genetic Testing Reported with Unlisted Codes: ICD-10 Diagnosis Codes

Non-Covered ICD-10 Diagnosis Codes

Non-Covered ICD-10 Diagnosis Codes List

This list contains ICD-10 diagnosis codes that are never covered when given as the primary reason for the test. If a code from this section is given as the reason for the test and you know or have reason to believe the service may not be covered, call UnitedHealthcare to issue an Integrated Denial Notice (IDN) to the member and

you. The IDN informs the member of their liability for the non-covered service or item and appeal rights. You must make sure the member has received the IDN prior to rendering or referring for non-covered services or items in order to collect payment.

QUESTIONS AND ANSWERS

1

Q: When should an unlisted code be used to report a service?

A: Unlisted codes should be reported only if no other specific codes adequately describe the procedure or

service.

2

Q: When reporting molecular pathology or genetic testing services with an unlisted code how is the specific test performed identified?

A: When reporting a laboratory test using an unlisted code, the specific name of the laboratory test(s) and/or a short descriptor of the test(s) must be included in the appropriate field of the claim form.

PURPOSE The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare

Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services. The document can be used as a guide to help determine applicable: • Medicare coding or billing requirements, and/or

• Medical necessity coverage guidelines; including documentation requirements. UnitedHealthcare follows Medicare guidelines such as LCDs, NCDs, and other Medicare manuals for the purposes of

determining coverage. It is expected providers retain or have access to appropriate documentation when requested to support coverage. Please utilize the links in the References section below to view the Medicare source materials used to develop this resource document. This document is not a replacement for the Medicare source materials that outline Medicare coverage requirements. Where there is a conflict between this document and Medicare source materials, the

Medicare source materials will apply. REFERENCES

CMS National Coverage Determination (NCD) NCD 90.2 Next Generation Sequencing (NGS)


https://www.uhcprovider.com/content/dam/provider/docs/public/policies/attachments/medadv/non-covered-icd10-dx-codes-mapg.pdf

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=372&ncdver=1&bc=AAAAIAAAAAAA&




CMS Local Coverage Determinations (LCDs) and Articles

LCD Article Contractor Medicare Part A Medicare Part B

L35396 Biomarkers for

Oncology

A52986 Billing and Coding:

Biomarkers for Oncology

Novitas

Solutions, Inc.

AR, CO, DC, DE,

LA, MD, MS, NJ, NM, OK, PA, TX

AR, CO, DC, DE,


L34864 Loss-of-

Heterozygosity Based Topographic Genotyping with Pathfinder TG®


Loss-of-Heterozygosity Based Topographic Genotyping with Pathfinder TG®

Novitas

Solutions, Inc.

AR, CO, DC, DE,


AR, CO, DC, DE,


L37266 MolDX: AlloSure® Donor-Derived Cell-Free DNA

Test

A56965 Billing and Coding: MolDX: AlloSure® Donor-

Derived Cell-Free DNA Test

Palmetto GBA AL, GA, NC, SC, TN, VA, WV

AL, GA, NC, SC, TN, VA, WV

L37362 MolDX: AlloSure®

Donor-Derived Cell-Free DNA Test


MolDX: AlloSure® Donor-Derived Cell-Free DNA Test

CGS

Administrators, LLC

KY, OH KY, OH

L37303 MolDX: AlloSure®

Donor-Derived Cell-Free DNA Test


MolDX: AlloSure® Donor-Derived Cell-Free DNA Test

Noridian

Healthcare Solutions, LLC

AS, CA, GU, HI,

MP, NV

AS, CA, GU, HI,

MP, NV

L37358 MolDX: AlloSure® Donor-Derived Cell-Free DNA Test

A57457 Billing and Coding: MolDX: AlloSure® Donor-Derived Cell-Free DNA Test

Noridian Healthcare Solutions, LLC

AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY


L37665 MolDX: AlloSure® Donor-Derived Cell-Free DNA

Test

A57557 Billing and Coding: MolDX: AlloSure® Donor-

Derived Cell-Free DNA Test

Wisconsin Physicians

Service Insurance Corporation

AK, AL, AR, AZ, CA, CO, CT, DE,

FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO,

MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH,

OK, OR, PA, RI, SC, SD, TN, TX,

UT, VA, VT, WA,

WI, WV, WY

IA, IN, KS, MI, MO, NE

L36004 MolDX: Genetic Testing for BCR-ABL Negative

Myeloproliferative Disease

A53531 Billing and Coding: MolDX: BCR-ABL



L36815 MolDX: Genetic

Testing for BCR-ABL Negative Myeloproliferative Disease


MolDx: BCR-ABL

Wisconsin

Physicians Service Insurance

Corporation

AK, AL, AR, AZ,

CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS,

KY, LA, MA, MD, ME, MI, MO, MS, MT, NC,

ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX,

UT, VA, VT, WA, WI, WV, WY

IA, IN, KS, MI,

MO, NE

L36180 MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease



AS, CA, GU, HI, MP, NV


L36186 MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease





https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35396&ver=190&articleId=52986&SearchType=Advanced&CoverageSelection=Local&ArticleType=BC%7cSAD%7cRTC%7cReg&PolicyType=Both&s=All&CptHcpcsCode=81479&kq=true&bc=EAAAABAAQAAA&


https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52986&ver=139&SearchType=Advanced&CoverageSelection=Local&ArticleType=BC%7cSAD%7cRTC%7cReg&PolicyType=Both&s=All&CptHcpcsCode=81479&kq=true&bc=EAAAABAAAAAA&
















https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37362&ver=9&Date=&DocID=L37362&bc=hAAAAAgAAAAA&
















































N/A A56270 Billing and Coding: MolDX: ClonoSEQ® Assay for

Assessment of Minimal Residual Disease (MRD) in Patients with Specific Lymphoid Malignancies



N/A A56277 Billing and Coding: MolDX: clonoSEQ® Assay for

Assessment of Minimal Residual Disease (MRD) in Patients with Specific

Lymphoid Malignancies




FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD,

ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH,

OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA,

WI, WV, WY


N/A A56307 Billing and Coding:

MolDX: ClonoSEQ® Assay for Assessment of Minimal Residual Disease (MRD) in

Patients with Specific Lymphoid Malignancies

CGS

Administrators, LLC

KY, OH KY, OH




Noridian


AS, CA, GU, HI,

MP, NV

AS, CA, GU, HI,

MP, NV




Noridian


AK, AZ, ID, MT,

ND, OR, SD, UT, WA, WY

AK, AZ, ID, MT,


N/A A54189 Billing and Coding: MolDX: cobas® EGFR Mutation Test Guidelines

CGS Administrators, LLC

KY, OH KY, OH

N/A A54199 Billing and Coding: MolDX: Therascreen® EGFR

RGQ PCR Kit Guidelines

CGS Administrators,

LLC

KY, OH KY, OH

L37857 MolDX: Envisia, Veracyte, Idiopathic

Pulmonary Fibrosis Diagnostic Test

A56898 Billing and Coding: MolDX: Envisia, Veracyte,

Idiopathic Pulmonary Fibrosis Diagnostic Test



L37905 MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic

Test

A56985 Billing and Coding: MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis

Diagnostic Test


KY, OH KY, OH

L37887 MolDX: Envisia,

Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test


MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test

Noridian


AS, CA, GU, HI,

MP, NV

AS, CA, GU, HI,

MP, NV

L37891 MolDX: Envisia,

Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic

Test


MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis

Diagnostic Test

Noridian


AK, AZ, ID, MT,


AK, AZ, ID, MT,






































https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37857&ver=9&articleId=56898&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&CptHcpcsCode=81479&clickon=search&bc=gAAAACAAQAAA&




https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=56898&ver=5&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&CptHcpcsCode=81479&clickon=search&bc=gAAAACAAAAAA&








https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=56985&ver=6&Date=&DocID=A56985&bc=ggAAAAgAAAAA&
























L37919 MolDX: Envisia, Veracyte, Idiopathic

Pulmonary Fibrosis Diagnostic Test

A57568 Billing and Coding: MolDX: Envisia, Veracyte,

Idiopathic Pulmonary Fibrosis Diagnostic Test




FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS,

MT, NC, ND, NE, NH, NJ, NM, NV,

OH, OK, OR, PA,

RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY


L35633 MolDX: GeneSight® Assay for Refractory Depression

A56927 Billing and Coding: MolDX: GeneSight® Assay for Refractory Depression



L35443 MolDX: GeneSight® Assay for Refractory

Depression

Billing and Coding: MolDX: A56936 GeneSight® Assay for

Refractory Depression

CGS Administrators,

LLC

KY, OH KY, OH

L36325 MolDX: GeneSight®

Assay for Refractory Depression


MolDX: GeneSight® Assay for Refractory Depression

Noridian


AK, AZ, ID, MT,


AK, AZ, ID, MT,









Wisconsin Physicians Service

Insurance Corporation

AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA,

ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO,

MS, MT, NC, ND, NE, NH, NJ,

NM, NV, OH,

OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY


L37649 MolDX: Guardant360® Plasma-Based Comprehensive

Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC)

A57425 Billing and Coding: MolDX: Guardant360®

Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer

(NSCLC)

Noridian Healthcare

Solutions, LLC



L37651 MolDX: Guardant360® Plasma-Based Comprehensive

Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC)

A57426 Billing and Coding: MolDX: Guardant360®

Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer

(NSCLC)

Noridian Healthcare

Solutions, LLC

AK, AZ, ID, MT, ND, OR, SD, UT,

WA, WY


WA, WY

L38043 MolDX: Plasma-Based

Genomic Profiling in Solid Tumors


MolDX: Plasma-Based Genomic Profiling in Solid Tumors

Palmetto GBA AL, GA, NC, SC,

TN, VA, WV

AL, GA, NC, SC,

TN, VA, WV

N/A A54193 Billing and Coding: MolDX: HERmark® Assay by Monogram


KY, OH KY, OH

L35160 MolDX: Molecular Diagnostic Tests (MDT)

A54437 Billing and Coding: MolDX: HERmark® Assay by

Monogram

Noridian Healthcare

Solutions, LLC































































https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=38043&ver=5&articleId=57867&SearchType=Advanced&CoverageSelection=Local&ArticleType=BC%7cSAD%7cRTC%7cReg&PolicyType=Both&s=All&KeyWord=Plasma-Based+Genomic+Profiling+in+Solid+Tumors&bc=AAAAAAAAQAAA&



https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=57867&ver=3&Date=&DocID=A57867&SearchType=Advanced&bc=EgAAAAgAAAAA&


















Monogram

Noridian Healthcare

Solutions, LLC


WA, WY


WA, WY



Monogram Update



L36807 MolDX: Molecular

Diagnostic Tests (MDT)


MolDX: HERmark® Assay by Monogram Update

Wisconsin


Corporation

AK, AL, AR, AZ,





IA, IN, KS, MI,

MO, NE

L37921 MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer

A56333 Billing and Coding: MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with

Lung Cancer




ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC,

ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI,

SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY


L37870 MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer

A56924 Billing and Coding: MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with

Lung Cancer



L37903 MolDX: Inivata,

InVisionFirst, Liquid Biopsy for Patients with Lung Cancer


MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer

CGS

Administrators, LLC

KY, OH KY, OH

L37897 MolDX: Inivata, InVisionFirst, Liquid Biopsy for

Patients with Lung Cancer

A57664 Billing and Coding: MolDX: Inivata, InVisionFirst,

Liquid Biopsy for Patients with Lung Cancer

Noridian Healthcare

Solutions, LLC



L37899 MolDX: Inivata,

InVisionFirst, Liquid Biopsy for Patients with Lung Cancer


MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer

Noridian


AK, AZ, ID, MT,


AK, AZ, ID, MT,


L36370 Genetic Testing for Lynch Syndrome

A56103 Billing and Coding: MolDX: Microsatellite

Instability-High (MSI-H) and Mismatch Repair Deficient (dMMR) Biomarker Billing and

Coding Guidelines for Patients with Unresectable or Metastatic Solid Tumors

Noridian Healthcare

Solutions, LLC





















































https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36370&ver=21&articleId=56103&Date=&DocID=A56103&bc=ggAAAAgAQAAA&















A56104 Billing and Coding: MolDX: Microsatellite

Instability-High (MSI-H) and Mismatch Repair Deficient (dMMR) Biomarker Billing and Coding Guidelines for Patients

with Unresectable or Metastatic Solid Tumors

Noridian Healthcare

Solutions, LLC


WA, WY


WA, WY


A56072 Billing and Coding: MolDX: Microsatellite Instability-High (MSI-H) and

Mismatch Repair Deficient (dMMR) Biomarker for Patients with Unresectable or Metastatic Solid Tumors



N/A A56106 Billing and Coding: MolDX: Microsatellite

Instability-High (MSI-H) and Mismatch Repair Deficient (dMMR) Biomarker for

Patients with Unresectable or Metastatic Solid Tumors

CGS Administrators,

LLC

KY, OH KY, OH


A56501 Billing and Coding: MolDX: Microsatellite Instability-High (MSI-H) and Mismatch Repair Deficient

(dMMR) Biomarker for Patients with Unresectable or Metastatic Solid Tumors

Wisconsin Physicians Service Insurance

Corporation

AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS,





L37701 MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate

Resistant Prostate Cancer (MCRPC)

A56964 Billing and Coding: MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with

Metastatic Castrate Resistant Prostate Cancer (MCRPC)



L37836 MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate

Resistant Prostate Cancer (MCRPC)

A57003 Billing and Coding: MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with

Metastatic Castrate Resistant Prostate Cancer (MCRPC)


KY, OH KY, OH

L37744 MolDX: Oncotype DX

AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer

(MCRPC)


MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant

Prostate Cancer (MCRPC)

Noridian


AK, AZ, ID, MT,


AK, AZ, ID, MT,


L37915 MolDX: Oncotype DX

AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC)


MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC)

Wisconsin

Physicians Service Insurance Corporation

AK, AL, AR, AZ,

CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD,

ME, MI, MO, MS, MT, NC,

ND, NE, NH, NJ,

NM, NV, OH, OK, OR, PA, RI,

IA, IN, KS, MI,

MO, NE
















































































SC, SD, TN, TX, UT, VA, VT, WA,

WI, WV, WY

L37746 MolDX: Oncotype DX AR-V7 Nucleus Detect for Men

with Metastatic Castrate Resistant Prostate Cancer (MCRPC)

A57601 Billing and Coding: MolDX: Oncotype DX AR-V7

Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC)

Noridian Healthcare

Solutions, LLC



L36886 MolDX: Percepta© Bronchial Genomic Classifier

A57502 Billing and Coding: MolDX: Percepta© Bronchial

Genomic Classifier

Noridian Healthcare

Solutions, LLC



L36891 MolDX: Percepta©

Bronchial Genomic Classifier


MolDX: Percepta© Bronchial Genomic Classifier

Noridian


AK, AZ, ID, MT,


AK, AZ, ID, MT,


L37195 MolDX: Percepta©

Bronchial Genomic Classifier


MolDX: Percepta© Bronchial Genomic Classifier

Wisconsin


Corporation

AK, AL, AR, AZ,





IA, IN, KS, MI,

MO, NE


A56849 Billing and Coding: MolDX: Percepta® Bronchial Genomic Classifier




A56972 Billing and Coding: MolDX: Percepta® Bronchial

Genomic Classifier

CGS Administrators,

LLC

KY, OH KY, OH

L36665 MolDX: ProMark Risk Score

A56957 Billing and Coding: MolDX: ProMark Risk Score





Noridian Healthcare

Solutions, LLC



L37011 MolDX: ProMark Risk

Score


MolDX: ProMark Risk Score

Wisconsin


Corporation

AK, AL, AR, AZ,


KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ,

NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX,


IA, IN, KS, MI,

MO, NE






L36675 MolDX: ProMark Risk

Score


MolDX- CDD: ProMark Risk Score

CGS

Administrators, LLC

KY, OH KY, OH





























































L38059 MolDX: Prospera™ A57859 Billing and Coding: MolDX: Prospera™

CGS Administrators,

LLC

KY, OH KY, OH

L38041 MolDX: Prospera™ A57825 Billing and Coding: MolDX: Prospera™



N/A A54901 Billing and Coding: MolDX: Targeted and

Comprehensive Genomic Profile Next Generation Sequencing Testing in Cancer

CGS Administrators,

LLC

KY, OH KY, OH


A55197 Billing and Coding: MolDX: Targeted and

Comprehensive Genomic Profile Next Generation Sequencing Testing in Cancer







WI, WV, WY



Comprehensive Genomic Profile Next-Generation Sequencing Testing in Cancer




Comprehensive Genomic Profile Next-Generation

Sequencing Testing in Cancer

Noridian Healthcare

Solutions, LLC



N/A A56518 Billing and Coding: MolDX: Targeted and Comprehensive Genomic

Profile Next-Generation Sequencing Testing in Cancer




L38039 MolDX: TruGraf Blood Gene Expression Test

A57350 Billing and Coding: MolDX: TruGraf Blood Gene Expression Test




A57446 Billing and Coding: MolDX: TruGraf Blood Gene

Expression Test

CGS Administrators,

LLC

KY, OH KY, OH


A57746 Billing and Coding: MolDX: Trugraf Blood Gene

Expression Test

Noridian Healthcare

Solutions, LLC



L38137 MolDX: TruGraf Blood

Gene Expression Test


MolDX: Trugraf Blood Gene Expression Test

Noridian


AK, AZ, ID, MT,


AK, AZ, ID, MT,



A57629 Billing and Coding: MolDX: TruGraf® Blood Gene Expression Test




ID, IL, IN, KS, KY, LA, MA, MD,


ND, NE, NH, NJ, NM, NV, OH,


https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=38059&ver=3&DocID=L38059&bc=gAAAAAgAAAAA&

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=57859&ver=3&DocID=A57859&bc=gAAAAAgAAAAA&


https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=38041&ver=3&articleId=57825&DocID=A57825&bc=gAAAAAgAQAAA&





























































L37733 Biomarker Testing

(Prior to Initial Biopsy) for Prostate Cancer Diagnosis


Biomarker Testing (Prior to Initial Biopsy) for Prostate Cancer Diagnosis

National

Government Services, Inc.

CT, IL, MA, ME,

MN, NH, NY, RI, VT, WI

CT, IL, MA, ME,

MN, NH, NY, RI, VT, WI


A55137 Billing and Coding: MolDX 4q25-AF Risk

Genotype Testing







WI, WV, WY



MolDX: 4q25-AF Risk Genotype


TN, VA, WV

AL, GA, NC, SC,

TN, VA, WV


MolDX: 4q25-AF Risk Genotype

Noridian


AS, CA, GU, HI,

MP, NV

AS, CA, GU, HI,

MP, NV

N/A A55091 Billing and Coding: MolDX: 4q25-AF Risk Genotype




N/A A54241 Billing and Coding: MolDX: 4q25-AF Risk

Genotype Guidelines

CGS Administrators,

LLC

KY, OH KY, OH

N/A A53657 Billing and Coding: MolDX: 9p21 Genotype Test




CGS Administrators,

LLC

KY, OH KY, OH


MolDX: 9p21 Genotype Test

Noridian


AS, CA, GU, HI,

MP, NV

AS, CA, GU, HI,

MP, NV






A55138 Billing and Coding: MolDX: 9p21 Genotype Test

















































N/A A55088 Billing and Coding: MolDX: Aspartoacyclase 2

Deficiency (ASPA) Testing

Noridian Healthcare

Solutions, LLC



N/A A55089 Billing and Coding: MolDX: Aspartoacyclase 2

Deficiency (ASPA) Testing

Noridian Healthcare

Solutions, LLC


WA, WY


WA, WY




MolDX: Aspartoacyclase 2 Deficiency (ASPA) Testing

Wisconsin


Corporation

AK, AL, AR, AZ,





IA, IN, KS, MI,

MO, NE

N/A A53602 Billing and Coding: MolDX: Aspartoacyclase 2 Deficiency (ASPA) Testing



N/A A54253 Billing and Coding: MolDX: Aspartoacyclase 2 Deficiency (ASPA) Testing


KY, OH KY, OH

N/A A53550 Billing and Coding: MolDX: ATP7B Gene Tests




CGS Administrators,

LLC

KY, OH KY, OH


MolDX: ATP7B Gene Tests

Noridian


AS, CA, GU, HI,

MP, NV

AS, CA, GU, HI,

MP, NV






A55143 Billing and Coding: MolDX: ATP7B Gene Tests





MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI,



N/A A53484 Billing and Coding: MolDX: BluePrint® Test




CGS Administrators,

LLC

KY, OH KY, OH


MolDX: BluePrint® Test

Noridian

Healthcare

Solutions, LLC

AS, CA, GU, HI,

MP, NV

AS, CA, GU, HI,

MP, NV









































Noridian Healthcare

Solutions, LLC


WA, WY


WA, WY


A55146 Billing and Coding: MolDX: BluePrint® Test





ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ,

NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA,

WI, WV, WY



MolDX: CFTR Gene Analysis


TN, VA, WV

AL, GA, NC, SC,

TN, VA, WV


MolDX: CFTR Gene Analysis

CGS

Administrators, LLC

KY, OH KY, OH

N/A A55117 Billing and Coding: MolDX: CFTR Gene Analysis




N/A A55118 Billing and Coding: MolDX: CFTR Gene Analysis





A55156 Billing and Coding: MolDX: CFTR Gene Analysis


Service Insurance

Corporation


FL, GA, HI, IA, ID, IL, IN, KS,

KY, LA, MA, MD,



WI, WV, WY



MolDX: CHD7 Gene Analysis


TN, VA, WV

AL, GA, NC, SC,

TN, VA, WV



Noridian


AS, CA, GU, HI,

MP, NV

AS, CA, GU, HI,

MP, NV





Wisconsin


Corporation

AK, AL, AR, AZ,





IA, IN, KS, MI,

MO, NE































N/A A54243 Billing and Coding: MolDX: CHD7 Gene Analysis

Guidelines

CGS Administrators,

LLC

KY, OH KY, OH

N/A A55086 MolDX: CHD7 Gene Analysis Coding and Billing

Guidelines

Noridian Healthcare

Solutions, LLC


WA, WY


WA, WY


MolDX: CYP2B6 Test


TN, VA, WV

AL, GA, NC, SC,

TN, VA, WV


MolDX: CYP2B6 Test

CGS

Administrators, LLC

KY, OH KY, OH

N/A A55177 Billing and Coding: MolDX: CYP2B6 Test




N/A A55178 Billing and Coding: MolDX: CYP2B6 Test





A55234 Billing and Coding: MolDX: CYP2B6 Test







WI, WV, WY


L35072 MolDX: CYP2C19,

CYP2D6, CYP2C9, and VKORC1 Genetic Testing


MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing


TN, VA, WV

AL, GA, NC, SC,

TN, VA, WV

L35332 MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing

A56864 Billing and Coding: MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic

Testing


KY, OH KY, OH





Noridian


AS, CA, GU, HI,

MP, NV

AS, CA, GU, HI,

MP, NV

L36312 MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing

A57522 Billing and Coding: MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic

Testing








Wisconsin


Corporation

AK, AL, AR, AZ,


KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE,

NH, NJ, NM, NV, OH, OK, OR, PA,

RI, SC, SD, TN, TX, UT, VA, VT,

WA, WI, WV, WY

IA, IN, KS, MI,

MO, NE


























































N/A A53536 Billing and Coding: MolDX: ENG and ACVRL1

Gene Tests



N/A A54262 Billing and Coding: MolDX: ENG and ACVRL1

Gene Tests

CGS Administrators,

LLC

KY, OH KY, OH




MolDX: ENG and ACVRL1 Gene Tests

Wisconsin


Corporation

AK, AL, AR, AZ,





IA, IN, KS, MI,

MO, NE

N/A A55181 Billing and Coding: MolDX: ENG and ACVRL1 Gene Tests




N/A A55182 Billing and Coding: MolDX: ENG and ACVRL1 Gene Tests




N/A A53619 Billing and Coding: MolDX: HAX1 Gene

Sequencing




MolDX: HAX1 Gene Sequencing

CGS

Administrators, LLC

KY, OH KY, OH


A55165 Billing and Coding: MolDX: HAX1 Gene Sequencing


Corporation






N/A A55249 Billing and Coding: MolDX: HAX1 Gene Sequencing




N/A A55252 Billing and Coding: MolDX: HAX1 Gene

Sequencing

Noridian Healthcare

Solutions, LLC


WA, WY


WA, WY


MolDX: HTTLPR Gene Testing


TN, VA, WV

AL, GA, NC, SC,

TN, VA, WV



CGS

Administrators, LLC

KY, OH KY, OH












































A55169 Billing and Coding: MolDX: HTTLPR Gene Testing






NM, NV, OH,


WI, WV, WY


N/A A55264 Billing and Coding: MolDX: HTTLPR Gene Testing

Noridian Healthcare

Solutions, LLC





Noridian


AK, AZ, ID, MT,


AK, AZ, ID, MT,


N/A A53576 Billing and Coding: MolDX: KIF6 Genotype





KY, OH KY, OH







NM, NV, OH,




Noridian Healthcare

Solutions, LLC




MolDX: KIF6 Genotype

Noridian


AK, AZ, ID, MT,


AK, AZ, ID, MT,


N/A A53467 Billing and Coding: MolDX: LPA-Aspirin Genotype




MolDX: LPA-Aspirin Genotype

CGS

Administrators, LLC

KY, OH KY, OH


A55173 Billing and Coding: MolDX: LPA-Aspirin Genotype





ND, NE, NH, NJ,


SC, SD, TN, TX,






































Noridian Healthcare

Solutions, LLC


WA, WY


WA, WY


MolDX: LPA-Intron 25 Genotype


TN, VA, WV

AL, GA, NC, SC,

TN, VA, WV

N/A A54276 Billing and Coding: MolDX: LPA-Intron 25 Genotype


KY, OH KY, OH


A55174 Billing and Coding: MolDX: LPA-Intron 25 Genotype








N/A A55281 Billing and Coding: MolDX: LPA-Intron 25

Genotype

Noridian Healthcare

Solutions, LLC




MolDX: LPA-Intron 25 Genotype

Noridian


AK, AZ, ID, MT,


AK, AZ, ID, MT,


N/A A53574 Billing and Coding: MolDX: MECP2 Genetic




MolDX: MECP2 Genetic Testing

CGS

Administrators, LLC

KY, OH KY, OH


A55189 Billing and Coding: MolDX: MECP2 Genetic Testing








N/A A55285 MolDX: MECP2 Genetic Testing Billing and

Coding Guidelines

Noridian Healthcare

Solutions, LLC



N/A A55286 MolDX: MECP2

Genetic Testing Billing and

Coding Guidelines

Noridian

Healthcare

Solutions, LLC

AK, AZ, ID, MT,

ND, OR, SD, UT,

WA, WY

AK, AZ, ID, MT,

ND, OR, SD, UT,

WA, WY










































N/A A53669 Billing and Coding: MolDX: Mitochondrial Nuclear

Gene Tests




A55190 Billing and Coding: MolDX: Mitochondrial Nuclear

Gene Tests







WI, WV, WY



MolDX: Mitochondrial Nuclear Gene Tests

Noridian


AS, CA, GU, HI,

MP, NV

AS, CA, GU, HI,

MP, NV

N/A A55291 Billing and Coding: MolDX: Mitochondrial Nuclear Gene Tests




N/A A54288 Billing and Coding: MolDX: Mitochondrial Nuclear Gene Tests Guidelines


KY, OH KY, OH

N/A A53585 Billing and Coding: MolDX: NSD1 Gene Tests




CGS Administrators,

LLC

KY, OH KY, OH




MolDX: NSD1 Gene Tests

Wisconsin

Physicians Service Insurance Corporation

AK, AL, AR, AZ,

CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD,


NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX,


IA, IN, KS, MI,

MO, NE









N/A A53664 Billing and Coding: MolDX: PAX6 Gene

Sequencing






MolDX: PAX6 Gene Sequencing

Wisconsin

Physicians Service


AK, AL, AR, AZ,

CA, CO, CT, DE, FL, GA, HI, IA,

ID, IL, IN, KS, KY, LA, MA, MD,


IA, IN, KS, MI,

MO, NE










































ND, NE, NH, NJ, NM, NV, OH,


N/A A54293 Billing and Coding: MolDX: PAX6 Gene

Sequencing Guidelines

CGS Administrators,

LLC

KY, OH KY, OH

N/A A55625 MolDX: PAX6 Gene

Sequencing Billing and Coding Guidelines

Noridian


AS, CA, GU, HI,

MP, NV

AS, CA, GU, HI,

MP, NV

N/A A55632 MolDX: PAX6 Gene Sequencing Billing and Coding Guidelines




L37260 MolDX: Prometheus IBD sgi Diagnostic Policy

A56933 Billing and Coding: MolDX: Prometheus IBD sgi Diagnostic Policy



N/A A56940 Billing and Coding: MolDX: Prometheus IBD sgi

Diagnostic Policy

CGS Administrators,

LLC

KY, OH KY, OH

L37299 MolDX: Prometheus

IBD sgi Diagnostic Policy


MolDX: Prometheus IBD sgi Diagnostic Policy

Noridian


AS, CA, GU, HI,

MP, NV

AS, CA, GU, HI,

MP, NV

L37313 MolDX: Prometheus

IBD sgi Diagnostic Policy


MolDX: Prometheus IBD sgi Diagnostic Policy

Noridian


AK, AZ, ID, MT,


AK, AZ, ID, MT,


L37539 MolDX: Prometheus IBD sgi Diagnostic Policy

A57588 Billing and Coding: MolDX: Prometheus IBD sgi Diagnostic Policy


Insurance

Corporation


ID, IL, IN, KS,

KY, LA, MA, MD, ME, MI, MO,




N/A A53567 Billing and Coding: MolDX: PTCH1 Gene Testing





KY, OH KY, OH


A55203 Billing and Coding: MolDX: PTCH1 Gene Testing







SC, SD, TN, TX, UT, VA, VT, WA,

WI, WV, WY















































Noridian Healthcare

Solutions, LLC




Noridian Healthcare

Solutions, LLC


WA, WY


WA, WY


MolDX: RPS19 Gene Tests


TN, VA, WV

AL, GA, NC, SC,

TN, VA, WV


MolDX: RPS19 Gene Tests

CGS

Administrators, LLC

KY, OH KY, OH


A55205 Billing and Coding: MolDX: RPS19 Gene Tests


Corporation






N/A A55610 Billing and Coding: MolDX: RPS19 Gene Tests




N/A A55614 Billing and Coding: MolDX: RPS19 Gene Tests

Noridian Healthcare

Solutions, LLC


WA, WY


WA, WY


MolDX: SULT4A1 Genetic Testing


TN, VA, WV

AL, GA, NC, SC,

TN, VA, WV

N/A A54283 Billing and Coding: MolDX: SULT4A1 Genetic Testing


KY, OH KY, OH


A55210 Billing and Coding: MolDX: SULT4A1 Genetic Testing








N/A A55596 Billing and Coding: MolDX: SULT4A1 Genetic

Testing

Noridian Healthcare

Solutions, LLC




MolDX: SULT4A1 Genetic Testing

Noridian


AK, AZ, ID, MT,


AK, AZ, ID, MT,



MolDX: TERC Gene Tests


TN, VA, WV

AL, GA, NC, SC,

TN, VA, WV








































N/A A54282 Billing and Coding: MolDX: TERC Gene Tests

CGS Administrators,

LLC

KY, OH KY, OH


A55211 Billing and Coding: MolDX: TERC Gene Tests







WI, WV, WY



MolDX: TERC Gene Tests

Noridian


AS, CA, GU, HI,

MP, NV

AS, CA, GU, HI,

MP, NV

N/A A55616 Billing and Coding: MolDX: TERC Gene Tests




N/A A53548 Billing and Coding: MolDX: VEGFR2 Tests



N/A A54279 Billing and Coding: MolDx: VEGFR2 Tests


KY, OH KY, OH


A55232 Billing and Coding: MolDX: VEGFR2 Tests


Service Insurance

Corporation


FL, GA, HI, IA, ID, IL, IN, KS,

KY, LA, MA, MD,



WI, WV, WY



MolDX: VEGFR2 Tests

Noridian


AS, CA, GU, HI,

MP, NV

AS, CA, GU, HI,

MP, NV

N/A A55469 Billing and Coding: MolDX: VEGFR2 Tests




L36358 MolDX: Biomarkers in Cardiovascular Risk Assessment

A54975 Billing and Coding MolDX: Arrhythmogenic Right Ventricular

Dysplasia/Cardiomyopathy (ARVD/C) Testing




L36362 MolDX: Biomarkers in Cardiovascular Risk Assessment

A54976 Billing and Coding: MolDX: Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy

(ARVD/C) Testing














































L38016 MolDX: DecisionDx-Melanoma

A56990 Billing and Coding: MolDX: DecisionDx-Melanoma

CGS Administrators,

LLC

KY, OH KY, OH



Noridian Healthcare

Solutions, LLC



L37748 MolDX: DecisionDx-

Melanoma


MolDX: DecisionDx-Melanoma

Noridian


AK, AZ, ID, MT,


AK, AZ, ID, MT,







A56636 Billing and Coding: MolDX: DecisionDX-Melanoma


Corporation






N/A A55293 Billing and Coding: MolDX: myPap™





MolDX: myPap™

CGS Administrators,

LLC

KY, OH KY, OH


MolDX: myPap™

Noridian


AS, CA, GU, HI,

MP, NV

AS, CA, GU, HI,

MP, NV

A53544 Billing and Coding: MolDX: myPap™






MolDX: myPap™

Wisconsin


Corporation

AK, AL, AR, AZ,





IA, IN, KS, MI,

MO, NE

N/A A54187 Billing and Coding: MolDX: Avise PG Assay


KY, OH KY, OH


A55144 Billing and Coding: MolDX: Avise PG Assay


Service Insurance

Corporation

AK, AL, AR, AZ, CA, CO, CT,

DE, FL, GA, HI, IA, ID, IL, IN,

KS, KY, LA, MA, MD, ME, MI,

MO, MS, MT, NC, ND, NE,
































https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=55195&ver=9&Date=04%2f01%2f2020&DocID=A55195&bc=ggAAAAgAAAAA&

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=55195&ver=9&Date=04%2f01%2f2020&DocID=A55195&bc=ggAAAAgAAAAA&











NH, NJ, NM, NV, OH, OK,

OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY


A53100 Billing and Coding: MolDX: Avise PG Assay Palmetto GBA




A54376 Billing and Coding: MolDX: Avise PG Assay

Noridian Healthcare

Solutions, LLC




Diagnostic Tests (MDT) A54378 Billing and Coding:

MolDX: Avise PG Assay

Noridian


AK, AZ, ID, MT,


AK, AZ, ID, MT,





MolDX: know error®

Wisconsin


Corporation

AK, AL, AR, AZ,

CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN,

KS, KY, LA, MA, MD, ME, MI, MO, MS, MT,

NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC,

SD, TN, TX, UT, VA, VT, WA, WI, WV, WY

IA, IN, KS, MI,

MO, NE

N/A A54273 Billing and Coding: MolDX: know error®

CGS Administrators,

LLC

KY, OH KY, OH


MolDX: know error®

Palmetto GBA AL, GA, NC,

SC, TN, VA, WV

AL, GA, NC,

SC, TN, VA, WV

N/A A55274 MolDX: Know error® Billing and Coding Guidelines

Update

Noridian Healthcare

Solutions, LLC



N/A A55275 MolDX: Know error®

Billing and Coding Guidelines Update

Noridian


AK, AZ, ID, MT,


AK, AZ, ID, MT,


CMS Claims Processing Manual Chapter 26; § 10.4-Items 14-33-Provider of Service or Supplier Information

Instructions for Not Otherwise Classified (NOC) Codes

Others Billing and Describing Not Otherwise Classified (NOC) Codes, WPS Instructions for Use of Not Otherwise Classified or Unlisted Codes, NGS Unlisted and Not Otherwise Classified Code Billing, Noridian

GUIDELINE HISTORY/REVISION INFORMATION Revisions to this summary document do not in any way modify the requirement that services be provided and

documented in accordance with the Medicare guidelines in effect on the date of service in question.

Date Action/Description

06/01/2020 • Updated and reformatted list of Non-Covered ICD-10 Diagnosis Codes; removed

Z04.8, Z13.3, and Z13.4

04/08/2020 • New Policy



























https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf

https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/not-otherwise-classified-billing/!ut/p/z0/fczRCsIgFIDhJ5LjFgxvKwqJSdFFOG_iNJ07JDrU1eu3J-jyh48fDGgwET_ksVKKGLYeTPe8SdnJRvD-2irO9-r82J1EfxD3Bi5g_oPt0GZ1VB7MgnVmFKcE2q9kXWEYLcuupDWProCOqbJUZ5e_VBwbA5ZCEznLXhQCRQ_L2ww_n3rmnw!!/

https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/job-aids-manuals/instructions%20for%20use%20of%20not%20otherwise%20classified%20(noc)%20or%20unlisted%20codes/!ut/p/z1/rVJdb4IwFP0t_gDSWwqlPJZvJILMOUdfDCIaMkBjnMv26wfG7AMjzri-NE3PPeeecy8S6BmJOj0U63RfbOq0bN6JoHOF-zbGJgQR8wB4YHGFhy5RKEGzDoBEDLjiGJYVj4lryEj8_GY-ocBNhwQyMbDqa6d6uHA4_K3-W9-0eaNvhTTkDo5AvbX-l8Focqv-OUD05_eEEhMl1UKzybq_mRYt-rOaIdHROx_HNQ7R1_ExkA7gLPGkcaHNqT7yXZ3JIZvGDGJ_aOvjYSMRAZq0HEW1LYus2I82y7xEyX73mp8qL_l3GoOHIn9D03qzq5rlPPJss2KJkiyFNGcslzLGlpKCM11iDDJpoWcqVfAKVCwjD64o2PhOhQ49WAFp6LXICyAmQOk_0xsxbekd4jMLXE27k354bVln1teqCnzc1t45b6tpe-p36eXB-3hcVeaCjWyirqt5e5VSPBh8ArxkpEY!/dz/d5/L3dHQSEvUUtRZy9nQSEh/#Z7_69MIG982N8UQ80QIJE9PJ000O0

https://med.noridianmedicare.com/web/jfb/topics/claim-submission/submission-errors-solutions/unlisted-procedure-and-noc-codes




TERMS AND CONDITIONS

The Medicare Advantage Policy Guidelines are applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates. These Policy Guidelines are provided for informational purposes, and do not constitute medical advice. Treating

physicians and healthcare providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.

Benefit coverage for health services is determined by the member specific benefit plan document* and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific

benefit plan document supersedes the Medicare Advantage Policy Guidelines. Medicare Advantage Policy Guidelines are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making.

UnitedHealthcare may modify these Policy Guidelines at any time by publishing a new version of the policy on this website. Medicare source materials used to develop these guidelines include, but are not limited to, CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Medicare Benefit Policy Manual, Medicare

Claims Processing Manual, Medicare Program Integrity Manual, Medicare Managed Care Manual, etc. The information presented in the Medicare Advantage Policy Guidelines is believed to be accurate and current as of the date of publication and is provided on an "AS IS" basis. Where there is a conflict between this document and Medicare source

materials, the Medicare source materials will apply. You are responsible for submission of accurate claims. Medicare Advantage Policy Guidelines are intended to ensure that coverage decisions are made accurately based on the code or codes that correctly describe the health care

services provided. UnitedHealthcare Medicare Advantage Policy Guidelines use Current Procedural Terminology (CPT®), Centers for Medicare and Medicaid Services (CMS), or other coding guidelines. References to CPT® or other sources are for definitional purposes only and do not imply any right to reimbursement or guarantee claims payment.

Medicare Advantage Policy Guidelines are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited.

*For more information on a specific member's benefit coverage, please call the customer service number on the back of the member ID card or refer to the Administrative Guide. C00.0 C00.1 C00.2 C00.3 C00.4 C00.5 C00.6 C00.8 C00.9 C01 C02.0 C02.1 C02.2 C02.3 C02.4 C02.8 C02.9 C03.0 C03.1 C03.9 C04.0 C04.1 C04.8 C04.9 C05.0 C05.1 C05.2 C05.8 C05.9 C06.0

C06.1 C06.2 C06.80 C06.89 C06.9 C07 C08.0 C08.1 C08.9 C09.0 C09.1 C09.8 C09.9 C10.0 C10.1 C10.2 C10.3 C10.4 C10.8 C10.9 C11.0 C11.1 C11.2 C11.3 C11.8 C11.9 C12 C13.0 C13.1 C13.2 C13.8 C13.9 C14.0 C14.2 C14.8 C15.3 C15.4 C15.5 C15.8 C15.9 C16.0 C16.1 C16.2 C16.3 C16.4 C16.5 C16.6 C16.8 C16.9 C17.0 C17.1 C17.2 C17.3 C17.8 C17.9 C18.0 C18.1 C18.2 C18.3 C18.4 C18.5 C18.6 C18.7 C18.8 C18.9 C19 C20 C21.0 C21.1 C21.2 C21.8 C22.0 C22.1 C22.2 C22.3 C22.4 C22.7 C22.8 C22.9 C23 C24.0 C24.1 C24.8 C24.9 C25.0 C25.1 C25.2

C25.3 C25.4 C25.7 C25.8 C25.9 C26.0 C26.1 C26.9 C30.0 C30.1 C31.0 C31.1 C31.2 C31.3 C31.8 C31.9 C32.0 C32.1 C32.2 C32.3 C32.8 C32.9 C33 C34.00 C34.01 C34.02 C34.10 C34.11 C34.12 C34.2 C34.30 C34.31 C34.32 C34.80 C34.81 C34.82 C34.90 C34.91 C34.92 C37 C38.0 C38.1 C38.2 C38.3 C38.4 C38.8 C39.0 C39.9 C40.00 C40.01 C40.02 C40.10 C40.11 C40.12 C40.20 C40.21 C40.22 C40.30 C40.31 C40.32 C40.80 C40.81 C40.82 C40.90 C40.91 C40.92 C41.0 C41.1 C41.2 C41.3 C41.4 C41.9 C43.0 C43.10 C43.111 C43.112 C43.121 C43.122 C43.20 C43.21 C43.22 C43.30 C43.31 C43.39 C43.4 C43.51 C43.52 C43.59 C43.60 C43.61 C43.62 C43.70 C43.71 C43.72 C43.8 C43.9 C44.00 C44.01 C44.02 C44.09 C44.101 C44.1021 C44.1022 C44.1091 C44.1092 C44.111 C44.1121 C44.1122 C44.1191 C44.1192 C44.121 C44.1221 C44.1222 C44.1291 C44.1292 C44.191

C44.1921 C44.1922 C44.1991 C44.1992 C44.201 C44.202 C44.209 C44.211 C44.212 C44.219 C44.221 C44.222 C44.229 C44.291 C44.292 C44.299 C44.300 C44.301 C44.309 C44.310 C44.311 C44.319 C44.320 C44.321 C44.329 C44.390 C44.391 C44.399 C44.40 C44.41 C44.42 C44.49 C44.500 C44.501 C44.509 C44.510 C44.511 C44.519 C44.520 C44.521 C44.529 C44.590 C44.591 C44.599 C44.601 C44.602 C44.609 C44.611 C44.612 C44.619 C44.621 C44.622 C44.629 C44.691 C44.692 C44.699 C44.701 C44.702 C44.709 C44.711 C44.712 C44.719 C44.721 C44.722 C44.729 C44.791 C44.792 C44.799 C44.80 C44.81 C44.82 C44.89 C44.90 C44.91 C44.92 C44.99 C45.0 C45.1 C45.2 C45.7 C45.9 C47.0 C47.10 C47.11 C47.12 C47.20 C47.21 C47.22 C47.3 C47.4 C47.5 C47.6 C47.8 C47.9 C48.0 C48.1 C48.2 C48.8 C49.0 C49.10 C49.11 C49.12 C49.20 C49.21 C49.22 C49.3 C49.4 C49.5 C49.6 C49.8 C49.9 C49.A0 C49.A1 C49.A2 C49.A3 C49.A4

C49.A5 C49.A9 C4A.0 C4A.10 C4A.111 C4A.112 C4A.121 C4A.122 C4A.20 C4A.21 C4A.22 C4A.30 C4A.31 C4A.39 C4A.4 C4A.51 C4A.52 C4A.59 C4A.60 C4A.61 C4A.62 C4A.70 C4A.71 C4A.72 C4A.8 C4A.9 C50.011 C50.012 C50.019 C50.021 C50.022 C50.029 C50.111 C50.112 C50.119 C50.121 C50.122 C50.129 C50.211 C50.212 C50.219 C50.221 C50.222 C50.229 C50.311 C50.312 C50.319 C50.321 C50.322 C50.329 C50.411 C50.412 C50.419 C50.421 C50.422 C50.429 C50.511 C50.512 C50.519 C50.521 C50.522 C50.529 C50.611 C50.612 C50.619 C50.621 C50.622 C50.629 C50.811 C50.812 C50.819 C50.821 C50.822 C50.829 C50.911 C50.912 C50.919 C50.921 C50.922 C50.929 C51.0 C51.1 C51.2 C51.8 C51.9 C52 C53.0 C53.1 C53.8 C53.9 C54.0 C54.1 C54.2 C54.3 C54.8 C54.9 C55 C56.1 C56.2 C56.9 C57.00 C57.01 C57.02 C57.10 C57.11 C57.12 C57.20 C57.21 C57.22 C57.3 C57.4 C57.7 C57.8 C57.9 C58 C60.0

C60.1 C60.2 C60.8 C60.9 C61 C62.00 C62.01 C62.02 C62.10 C62.11 C62.12 C62.90 C62.91 C62.92 C63.00 C63.01 C63.02 C63.10 C63.11 C63.12 C63.2 C63.7 C63.8 C63.9 C64.1 C64.2 C64.9 C65.1 C65.2 C65.9 C66.1 C66.2 C66.9 C67.0 C67.1 C67.2 C67.3 C67.4 C67.5 C67.6 C67.7 C67.8 C67.9 C68.0 C68.1 C68.8 C68.9 C69.00 C69.01 C69.02 C69.10 C69.11 C69.12 C69.20 C69.21 C69.22 C69.30 C69.31 C69.32 C69.40 C69.41 C69.42 C69.50 C69.51 C69.52 C69.60 C69.61 C69.62 C69.80 C69.81 C69.82 C69.90 C69.91 C69.92 C70.0 C70.1 C70.9 C71.0 C71.1 C71.2 C71.3 C71.4 C71.5 C71.6 C71.7 C71.8 C71.9 C72.0 C72.1 C72.20 C72.21 C72.22 C72.30 C72.31 C72.32 C72.40 C72.41 C72.42 C72.50 C72.59 C72.9 C73 C74.00 C74.01 C74.02 C74.10 C74.11 C74.12 C74.90 C74.91 C74.92 C75.0 C75.1 C75.2 C75.3 C75.4

C75.5 C75.8 C75.9 C76.0 C76.1 C76.2 C76.3 C76.40 C76.41 C76.42 C76.50 C76.51 C76.52 C76.8 C77.8 C77.9 C78.00 C78.1 C78.2 C78.30 C78.4 C78.5 C78.6 C78.7 C78.80 C78.89 C79.10 C79.11 C79.19 C79.31 C79.32 C79.40 C79.49 C79.51 C79.52 C79.60 C79.61 C79.62 C79.70 C79.71 C79.72 C79.81 C79.82 C79.89 C79.9 C7A.00 C7A.010 C7A.011 C7A.012 C7A.019 C7A.020 C7A.021 C7A.022 C7A.023 C7A.024 C7A.025 C7A.026 C7A.029 C7A.090 C7A.091 C7A.092 C7A.093 C7A.094 C7A.095 C7A.096 C7A.098 C7A.1 C7A.8 C7B.01 C7B.02 C7B.03 C7B.04 C7B.09 C7B.1 C7B.8 C80.0 C80.1 C80.2 C90.00 C90.01 C90.02 C91.00 C91.01 C91.02 C91.10 C91.11 C91.12 C92.00 C92.01 C92.02 C92.10 C92.11 C92.12 C92.20 C92.21 C92.22 C92.30 C92.32 C92.40 C92.41 C92.42 C92.50 C92.51 C92.52 C92.60 C92.61 C92.62 C92.A0 C92.A1 C92.A2 C92.Z0 C92.Z2 C93.10 C94.00 C94.02 C94.40

C94.41 C94.42 C94.6 D03.111 D03.112 D03.121 D03.122 D34 D3A.010 D3A.011 D3A.012 D3A.019 D3A.020 D3A.021 D3A.022 D3A.023 D3A.024 D3A.025 D3A.026 D3A.029 D3A.090 D3A.091 D3A.092 D3A.093 D3A.094 D3A.095 D3A.096 D3A.098 D3A.8 D44.0 D44.2 D44.9 D45 D46.0 D46.1 D46.20 D46.21 D46.22 D46.4 D46.9 D46.A D46.B D46.C D46.Z D47.02 D47.1 D47.3 D47.4 D47.9 D47.Z9 D72.821 D72.829 D75.1 D75.81 D75.89 D75.9 D86.0 E01.0 E01.1 E01.2 E04.0 E04.1 E04.2 E04.8 E04.9 F32.1 F32.2 F32.3 F32.4 F32.9 F33.1 F33.2 F33.3 F33.40 F33.41 F33.9 J60 J67.0 J67.1 J67.2 J67.3 J67.4 J67.5 J67.6 J67.7 J67.8 J67.9 J84.09 J84.10 J84.111 J84.112 J84.113 J84.114 J84.115 J84.116 J84.117 J84.2 J84.89 J84.9 K86.2 K86.3 M05.011 M05.012 M05.021 M05.022 M05.031 M05.032 M05.041 M05.042 M05.051 M05.052 M05.061 M05.062 M05.071 M05.072 M05.09

M05.111 M05.112 M05.121 M05.122 M05.131 M05.132 M05.141 M05.142 M05.151 M05.152 M05.161 M05.162 M05.171 M05.172 M05.19 M05.211 M05.212 M05.221 M05.222 M05.231 M05.232 M05.241 M05.242 M05.251 M05.252 M05.261 M05.262 M05.271 M05.272 M05.29 M05.311 M05.312 M05.321 M05.322 M05.331 M05.332 M05.341 M05.342 M05.351 M05.352 M05.361 M05.362 M05.371 M05.372 M05.39 M05.411 M05.412 M05.421 M05.422 M05.431 M05.432 M05.441 M05.442 M05.451 M05.452 M05.461 M05.462 M05.471 M05.472 M05.49 M05.511 M05.512 M05.521 M05.522 M05.531 M05.532 M05.541 M05.542 M05.551 M05.552 M05.561 M05.562 M05.571 M05.572 M05.59 M05.611 M05.612 M05.621 M05.622 M05.631 M05.632 M05.641 M05.642 M05.651 M05.652 M05.661 M05.662 M05.671 M05.672 M05.69 M05.711 M05.712 M05.721 M05.722 M05.731 M05.732 M05.741 M05.742 M05.751 M05.752 M05.761 M05.762 M05.771 M05.772 M05.79 M05.811 M05.812 M05.821 M05.822 M05.831 M05.832 M05.841 M05.842 M05.851 M05.852 M05.861

M05.862 M05.871 M05.872 M05.89 M06.011 M06.012 M06.021 M06.022 M06.031 M06.032 M06.041 M06.042 M06.051 M06.052 M06.061 M06.062 M06.071 M06.072 M06.09 M06.211 M06.212 M06.221 M06.222 M06.231 M06.232 M06.241 M06.242 M06.251 M06.252 M06.261 M06.262 M06.271 M06.272 M06.29 M06.311 M06.312 M06.321 M06.322 M06.331 M06.332 M06.341 M06.342 M06.351 M06.352 M06.361 M06.362 M06.371 M06.372 M06.39 M06.811 M06.812 M06.821 M06.822 M06.831 M06.832 M06.841 M06.842 M06.851 M06.852 M06.861 M06.862 M06.871 M06.872 M06.89 R91.1 R91.8 R99 T86.10 Z00.00 Z00.01 Z00.110 Z00.111 Z00.121 Z00.129 Z00.5 Z00.70 Z00.71 Z00.8 Z02.0 Z02.1 Z02.2 Z02.3 Z02.4 Z02.5 Z02.6 Z02.71 Z02.79 Z02.81 Z02.82 Z02.83 Z02.89 Z02.9 Z04.6 Z04.8 Z04.81 Z04.82 Z04.89 Z04.9 Z11.0 Z11.1 Z11.2 Z11.3 Z11.4 Z11.51 Z11.59 Z11.6 Z11.7 Z11.8 Z11.9 Z12.0 Z12.10 Z12.13 Z12.2 Z12.6 Z12.71 Z12.72

Z12.73 Z12.79 Z12.81 Z12.82 Z12.83 Z12.89 Z12.9 Z13.0 Z13.21 Z13.220 Z13.228 Z13.29 Z13.3 Z13.30 Z13.31 Z13.32 Z13.39 Z13.4 Z13.40 Z13.41 Z13.42 Z13.49 Z13.5 Z13.71 Z13.79 Z13.810 Z13.811 Z13.818 Z13.820 Z13.828 Z13.83 Z13.84 Z13.850 Z13.858 Z13.88 Z13.89 Z13.9 Z19.2 Z36.0 Z36.1 Z36.2 Z36.3 Z36.4 Z36.5 Z36.81 Z36.82 Z36.83 Z36.84 Z36.85 Z36.86 Z36.87 Z36.88 Z36.89 Z36.8A Z36.9 Z40.00 Z40.01 Z40.02 Z40.09 Z40.8 Z40.9 Z41.1 Z41.2 Z41.3 Z41.8 Z41.9 Z46.1 Z48.22 Z56.0 Z56.2 Z56.3 Z56.4 Z56.5 Z56.6 Z56.81 Z56.82 Z56.89 Z56.9 Z57.0 Z57.1 Z57.2 Z57.31 Z57.39 Z57.4 Z57.5 Z57.6 Z57.7 Z57.8 Z57.9 Z59.0 Z59.1 Z59.2 Z59.3 Z59.4 Z59.5 Z59.6 Z59.7 Z59.8 Z59.9 Z60.2 Z62.21 Z71.0 Z74.1 Z74.2 Z74.3 Z74.8 Z74.9 Z75.5 Z76.0 Z76.1 Z76.2 Z76.3 Z76.4 Z76.81 Z79.899 Z80.1

Z80.2 Z80.49 Z80.51 Z80.52 Z80.59 Z80.6 Z80.7 Z80.8 Z80.9 Z81.0 Z81.1 Z81.2 Z81.3 Z81.4 Z81.8 Z82.0 Z82.1 Z82.2 Z82.3 Z82.41 Z82.49 Z82.5 Z82.61 Z82.62 Z82.69 Z82.71 Z82.79 Z82.8 Z83.0 Z83.1 Z83.2 Z83.3 Z83.41 Z83.49 Z83.511 Z83.518 Z83.52 Z83.6 Z83.71 Z83.79 Z84.0 Z84.1 Z84.2 Z84.3 Z84.81 Z84.89 Z85.46 Z92.21 Z92.25 Z92.29 Z94.0

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