Policy Number

Policy Name

Policy Summary

CG.CP.MP.01

Infectious Disease: Respiratory Lab Testing

This policy outlines criteria for Syndromic/Multiplex Respiratory Panels with 6 or More Targets, SARS-CoV-2, RSV, or Influenza A/B, OR Multiplex Respiratory Viral Panels with 5 or Fewer Targets, Bacterial Respiratory Infection/Pneumonia Panels, Influenza A and B Antibody Tests, Group A Streptococcus Pharyngitis Tests, Group A Streptococcus Pharyngitis Cultures, and Group A Streptococcus Antibody Tests.

CG.CP.MP.02

Infectious Disease:
Multi-System Lab Testing

This policy outlines the appropriate use of tests for pathogens that can cause multisystem symptoms and/or infections. Tests for pathogens that infect multiple body systems can be targeted to detect a specific pathogen(s) or non-targeted to broadly detect nucleic acid from any potential pathogen.

CG.CP.MP.03

Infectious Disease: Dermatologic Testing

This policy outlines the appropriate use of Microscopy/Peroxidase Tests, Fungal Culture, and Culture-Independent Molecular Tests (NAAT/PCR) for Onychomycosis.

CG.CP.MP.04

Infectious Disease: Gastroenterologic Lab Testing

This policy outlines appropriate use of multi-pathogen panels, as well as diagnostic assays targeted at Helicobacter pylori (H. pylori).

CG.CP.MP.05

Infectious Disease Primary Care and Preventive Lab Screening

This policy outlines criteria for human papillomavirus (HPV), hepatitis C virus (HCV), and group B streptococcus (GBS).

CG.CP.MP.06

Infectious Disease: Vector-Borne and Tropical Diseases Lab Testing

This policy outlines criteria for Lyme disease and Zika virus testing via serologic and molecular methods.

CG.CP.MP.07

Infectious Disease: Genitourinary Lab Testing

This policy outlines criteria for Targeted Vaginitis/Vaginosis Pathogen Testing, Expanded Multiplex Vaginitis/Vaginosis Pathogen Panels, Urine Culture for Asymptomatic Bacteriuria, and Molecular/Multiplex UTI Panels.

CG.PP.551A

Genetic and Molecular Testing-Version A

This payment policy is supporting the entire Concert genetic testing QAI program. Concert outreaches to labs that have not already registered with them to inform them of the GTU and which codes are assigned to their tests as payable (never more than 5 per test), but registration is not required for them to have claims edited upon. This version (A) requires Concert’s unique genetic test identifier, the GTU, on every genetic testing claim.

CG.PP.551C

Genetic and Molecular Testing-Version C

This payment policy is supporting the entire Concert genetic testing QAI program. Concert outreaches to labs that have not already registered with them to inform them of the GTU and which codes are assigned to their tests as payable (never more than 5 per test), but registration is not required for them to have claims edited upon. This version (B) only requires a procedure code description (recommended to use the GTU but test name would also suffice) for the non-specific codes, 81479, 81599 and Tier 2 Codes.

CG.CC.PP.01

Concert Laboratory Payment Policy

This policy outlines correct coding requirements for lab testing, excluding and molecular testing

Policy Name

Revision Log Details

Applicable Lines of Business

Infectious Disease Respiratory Testing- CG.CP.MP.01

Annual review. Changed verbiage in applicable policy statements from “may be considered medically necessary” to “are considered medically necessary.” References reviewed and updated. For Group A Streptococcus Pharyngitis Cultures: Expanded coverage criteria to include patients up to 18 years old (was previously up to 14 years old); updated background and rationale to include language from the updated 2024 American Academy of Family Physicians evidence review. Added 0528U as an in-scope CPT code. Removed deleted codes U0003, U0004, and U0005. Reordered codes in CPT code table numerically. References reviewed and updated.

Wellcare

Wellcare By Meridian D-SNP

Meridian Medicaid Plan

YouthCare HealthChoice

Ambetter Health

Infectious Disease Multisystem Lab Testing-CG.CP.MP.02

Annual Review. In policy statements for the following criteria sections, changed policy to note that tests “are considered medically necessary” from the previous statement that they “may be considered medically necessary”: Cytomegalovirus (CMV) Nucleic Acid/PCR or Antigen Detection Tests; Cytomegalovirus (CMV) Antibody Tests. For Untargeted Metagenomic Sequencing Tests for Pathogen Detection: Added Bacteria, Viruses, Fungus, and Parasite Metagenomic Sequencing, Spinal Fluid (MSCSF) (Mayo Clinic) to the Policy Reference Table and updated related background. References reviewed and updated.

Wellcare

Wellcare By Meridian D-SNP

Meridian Medicaid Plan

YouthCare HealthChoice

Ambetter Health

Infectious Disease Dermatologic Testing- CG.CP.MP.03

Annual review. For Fungal Culture for Onychomycosis and Microscopy/Peroxidase Tests for Onychomycosis, reworded policy statements from “may be considered medically necessary” to “are considered medically necessary.”

Wellcare

Wellcare By Meridian D-SNP

Meridian Medicaid Plan

YouthCare HealthChoice

Ambetter Health

Infectious Disease Gastroenterological Lab Testing- CG.CP.MP.04

Annual review. Minor rewording with no clinical significance. For Syndromic/Multiplex Gastrointestinal Pathogen Panels with 11 or Fewer Targets: Changed policy statement from “may be considered medically necessary” to " are considered medically necessary.” Added 87650 and 0369U to Coding Table.

Wellcare

Wellcare By Meridian D-SNP

Meridian Medicaid Plan

YouthCare HealthChoice

Ambetter Health

Infectious Disease Primary Care & Preventive Lab Screening- CG.CP.MP.05

Annual review. Changed policy statement verbiage from " may be considered medically necessary" to "are considered medically necessary" for the following criteria sections: Group B Streptococcus Screening Tests of Vaginal-Rectal Specimens, Genotyping of High-Risk Human Papillomavirus (HPV) Types for Cervical Cancer Screening, and Hepatitis C Nucleic Acid/PCR Tests. For Hepatitis C Nucleic Acid/PCR Tests, added the following criteria option: "The member was exposed to HCV perinatally and is between 2 months and 17 months of age". Background updated. Codes added to CPT Coding table: 0500T, 87626. Code added to new HCPCS table: G0476. References updated.

Wellcare

Wellcare By Meridian D-SNP

Meridian Medicaid Plan

YouthCare HealthChoice

Ambetter Health

Infectious Disease Vector-borne and Tropical Disease Testing- CG.CP.MP.06

Annual review. Corrected 03/24 revision log to note that 86353 was removed from the CPT table. Minor rewording and formatting with no clinical significance. Reworded policy statements from “may be considered medically necessary” to “are considered medically necessary” for the following criteria sections: Lyme Disease (Borrelia burgdorferi) Serum Antibody Tests, Lyme Disease (Borrelia burgdorferi) Nucleic Acid/PCR Tests, Zika Virus Antibody Tests, and Zika Virus Nucleic Acid/PCR Tests. References updated.

Wellcare

Wellcare By Meridian D-SNP

Meridian Medicaid Plan

YouthCare HealthChoice

Ambetter Health

Infectious Disease Genitourinary Lab Testing- CG.CP.MP.07

Annual review. Minor rewording without clinical significance. For Urine Culture for Asymptomatic Bacteriuria: Addition of Urinary Tract Infection Testing (NxGen MDx, LLC) to Policy Reference Table. Changed policy statements for the following criteria sections from “may be considered medically necessary” to “are considered medically necessary”: Targeted Vaginitis/Vaginosis Pathogen Testing, For Expanded Multiplex Vaginitis/Vaginosis Pathogen Panels: Addition of Vaginal Infection Testing (NxGen MDx, LLC) to Policy Reference Table. Additional codes added to coding table: 87510, 87660, 87808, 87810, 87850, 0371U, 0372U, 0374U, 0504U, 81515, 87528, 87529, 87530, 87531, 87532, 87533, 87534, 87535, 87536, 87537, 87538, 87539, 87901, 87903, 87904, 87906. Removed deleted code 0352U.Background and references updated.

Wellcare

Wellcare By Meridian D-SNP

Meridian Medicaid Plan

YouthCare HealthChoice

Ambetter Health

Genetic and Molecular Testing- Version A ---CG.PP.551A

Annual Review. Minor rewording throughout. Removed “Policy Description” header. In Policy Overview, updated vendor name to “Concert”. In “Application”: replaced first sentence regarding “molecular pathology, genomic sequencing…” with Pathology and Laboratory Procedures (80000 Codes), Category III Multianalyte Assays with Algorithmic Analyses (MAAA) (M codes), Proprietary Lab Analysis (PLA) (U codes), Level II Healthcare Common Procedure Coding System (HCPCS);” updated URL to https://www.concertgenetics.com/join-centene. In the Reimbursement section reworded “Laboratories should adhere…” to “All providers of genetic and molecular testing services…”. In the Reimbursement section, added: requirement that billing should be consistent with what is delivered on the test result; requirement to add rendering provider information on the claim; requirements to add appropriate ICD-10 codes and place of service codes to claims; that coding must be consistent with NCCI guidelines; that if coding is not consistent with AMA and NCCI guidelines, payment may be denied; if a test has a PLA or MAAA code assigned, it must be billed, and PLA codes should only be billed for the specific test to which they are assigned; requirement for “if a test analyzes multiple analytes…”; 81599 as a non-specific procedure that may only be billed once per claim; requirement “codes may be used…”; requirement “modifier should be used…”; statement regarding use of Modifier 52; PTP and MUE requirements; requirement to “Bill for services according to the Concert coding engine standards”. Reordered GTU requirements to end of Reimbursement section under “Additional Requirements”. In “Additional Requirements”: added “All providers must follow these additional requirements…” and registration requirements. In the Reimbursement section, removed qualifier regarding the interpretation of AMA correct coding per the Concert Genetics Coding engine on the following verbiage: “the coding must be consistent with American Medical Association coding guidelines”. Table 1: Labeled table as codes for tests subject to GTU requirements; removed specific code range limits for PLA codes; added HCPCS codes for genetic and molecular testing. Table 2: labeled Table 2 as GTU Requirements; added 81479 to the Tier 2 code range. References updated.

Wellcare

Wellcare By Meridian D-SNP

Meridian Medicaid Plan

YouthCare HealthChoice

Ambetter Health

Concert Laboratory Payment Policy CG.CC.PP.01

Annual review. Added “Application” and “Reimbursement” section headers, with other restructuring. In applicable code ranges at the beginning of the policy, replaced “HCPCS level I codes for lab tests (G codes and S codes)” with Level II HCPCS and specified that in-scope codes are those unrelated to genetic and molecular tests, which are addressed by CG.PP.551. Combined AMA and NCCI coding requirements into one section and added details regarding NCCI manual instructions for billing panel codes. In reimbursement section: removed requirements for next generation sequencing as it is out of the policy’s scope; added requirement for billed units for tests analyzing multiple analytes; removed requirements for 81479 as it is specific to genetic and molecular testing; added requirement “modifier code should be used…”, added requirement “when interpretation of existing data…” References updated.

Wellcare

Wellcare By Meridian D-SNP

Meridian Medicaid Plan

YouthCare HealthChoice

Ambetter Health