Skip to Main Content

Print | Bookmark | Email | Font Size: + |

September 30, 2015 - Updated 05.11.21

MolDX LCDs

ID

Title / ID

Effective Date

Revision Effective Date

Last Updated

Status

HCPC/CPT Code

Related Policy Article(s)

L36979External Website

MolDX: 4Kscore Assay

3/13/17

4/1/21

3/26/21

Active

81539

A56944 – Billing and Coding: MolDX: 4Kscore AssayExternal Website

L38272External Website 

MolDX: AlloSure® or Equivalent Cell-Free DNA Testing for Kidney and Heart Allografts

12/28/20

NA

11/4/20

Active

Group 1 81479

Group 2 81479

A57167 – Billing and Coding: MolDX: AlloSure® or Equivalent Cell-Free DNA Testing for Kidney and Heart AllograftsExternal Website 

L37836External Website

MolDX: Androgen Receptor Variant (AR-V7) Protein Test

3/25/19

5/9/21

3/19/21

Future

81479

A57158 – Billing and Coding: MolDX: Androgen Receptor Variant (AR-V7) Protein TestExternal Website

L36910External Website

MolDX: APC and MUTYH Gene Testing

3/13/17

4/1/21

3/26/21

Active

Group 1: 81201, 81202, 81203, 81479

Group 2: 81401, 81403, 81406, 81435, 81436

Group 3: 0157U

A56828 – Billing and Coding: MolDX: APC and MUTYH GeneExternal Website

L37134External Website

MolDX: BDX-XL2

7/10/17

11/19/20

11/16/20

Active

0080U

A56947 – Billing and Coding: MolDX: BDX-XL2External Website

L38249External Website

MolDX: Blood Product Molecular Antigen Typing

11/1/20

12/10/20

12/1/20

Active

Group 1 21403, 0001U, 0084U

Group 2 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0221U, 0222U

A57155 – Billing and Coding: MolDX: Blood Product Molecular Antigen TypingExternal Website 

L36139External Website

MolDX: Biomarkers in Cardiovascular Risk Assessment

10/5/15

11/14/19

6/19/20

Active

81439, 82172, 82610, 83090, 83695, 83698, 83700, 83701, 83704, 83719, 83721, 86141

A54685 – Billing and Coding: MolDX: Arrhythmogenic Right Ventricular Dysplasia / Cardiomyopathy (ARVD / C) Testing Coding and Billing GuidelinesExternal Website

A57386 – Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk AssessmentExternal Website

L36456External Website

MolDX: BRCA1 and BRCA2 Genetic Testing

2/15/16

4/29/21

4/21/21

Active

Group 1: 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81432, 81433, 81479, 0102U, 0103U, 0129U

Group 2: 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U

Group 1: 81162

A56971 – Billing and Coding: MolDX: BRCA1 and BRCA2 Genetic TestingExternal Website

A54689 – Billing and Coding: MolDX: Myriad's BRACAnalysis CDx™External Website

L36425External Website

MolDX: Breast Cancer Assay: Prosigna

2/1/16

9/23/19

8/25/20

Active

81520

A56989 – Billing and Coding: MolDX: Breast Cancer Assay: ProsignaExternal Website

L37832External Website

MolDX: Breast Cancer™ (BCI) Gene Expression Test

4/1/19

5/2/21

3/22/21

Future

81518

A56884 – Billing and Coding: MolDX: Breast Cancer Index™ (BCI) Gene Expression TestExternal Website

L36006External Website

MolDX-CDD: ConfirmMDx Epigenetic Molecular Assay

10/5/15

4/22/21

4/16/21

Active

81551

A57031 – Billing and Coding: MolDX: ConfirmMDx Epigenetic Molecular AssayExternal Website

L36675External Website

MolDX - CDD: ProMark Risk Score

10/10/16

11/28/19

10/21/20

Active

81479

A57034 – Billing and Coding: MolDX – CDD: ProMark Risk ScoreExternal Website

L36973External Website

MolDX: Circulating Tumor Cell Marker Assays

3/6/17

5/6/21

4/29/21

Active

86152, 86153

A57288 – Billing and Coding: MolDX: Circulating Tumor Cell Marker AssaysExternal Website

L37787External Website

MolDX: Corus® CAD Assay

11/12/18

9/19/19

11/16/20

Active

81493

A56950 – Billing and Coding: MolDX: Corus® CAD AssayExternal Website

L37598External Website

MolDX: Cystatin C Measurement

12/17/18

12/10/20

12/1/20

Active

82610

A56988 – Billing and Coding: MolDX: Cystatin C MeasurementExternal Website

L38016External Website

MolDX: Melanoma Risk Stratification Molecular Testing

6/24/19

12/21/20

10/26/20

Active

81529, 81599

A57165 – Billing and Coding: MolDX: Melanoma Risk Stratification Molecular TestingExternal Website

L37130External Website

MolDX: DecisionDx-UM (Uveal Melanoma)

7/10/17

10/31/19

5/27/20

Active

81552

A56981 – Billing and Coding: MolDX: DecisionDx-UM (Uveal Melanoma)External Website

L37356External Website

MolDX: EndoPredict Breast Cancer Gene Expression Test

3/6/18

11/14/19

11/8/19

Active

81522

A56997 – Billing and Coding: MolDX: EndoPredict Breast Cancer Gene Expression TestExternal Website

L37905External Website

MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test

5/20/19

11/7/19

2/28/20

Active

81479

A56985 – Billing and Coding: MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic TestExternal Website

L36117External Website

MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease

10/5/15

12/19/19

6/30/20

Active

Group 1: 81206, 81207, 81208, 81219, 81270, 81402, 81479, 0040U

Group 2: 81403, 81445, 81450, 81455

A54686 – Billing and Coding: MolDX: BCR-ABLExternal Website

A56999 – Billing and Coding: MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative DiseaseExternal Website

L35984External Website

MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)

10/1/15

10/31/15

6/30/20

Active

81240, 81241, 81291

A56980 – Billing and Coding: MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)External Website

L35349External Website

MolDX: Genetic Testing for Lynch Syndrome

10/1/15

12/5/19

11/16/20

Active

Group 1: 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81479, 88341,88342, 0101U

Group 2: 81445, 81455, 0130U, 0134U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U

Group 3: 81301, 81403, 81435, 81436

A56882 – Billing and Coding: MolDX: Genetic Testing for Lynch SyndromeExternal Website

A56106 – Billing and Coding: MolDX: Microsatellite Instability-High (MSI-H) and Mismatch Repair Deficient (dMMR) Biomarker for Patients with Unresectable or Metastatic Solid TumorsExternal Website

L36485External Website

MolDX: HLA-DQB1*06:02 Testing for Narcolepsy

2/15/16

12/24/20

12/18/20

Active

81383

A56881 – Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for NarcolepsyExternal Website

L37903External Website

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

5/13/19

3/5/20

3/25/20

Active

81479

A56982 – Billing and Coding: MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung CancerExternal Website

L37608External Website

MolDX: MDS FISH

5/6/19

11/7/19

3/25/20

Active

88271, 88273, 88274, 88275, 88291

A56926 – Billing and Coding: MolDX: MDS FISHExternal Website

L36113External Website

MolDX: MGMT Promoter Methylation Analysis

10/5/15

6/4/20

5/26/20

Active

81287

A56983 – Billing and Coding: MolDX: MGMT Promoter Methylation AnalysisExternal Website

L38305External Website

MolDX: Minimal Residual Disease Testing for Colorectal Cancer

10/19/20

NA

8/26/20

Active

81479

A58330 - Billing and Coding: MolDX: Minimal Residual Disease Testing for Colorectal CancerExternal Website 

L38582External Website

MolDX: Molecular Testing for Solid Organ Allograft Rejection

6/6/21

NA

NA

Future

81479, 81595, 81599

A58061 – Billing and Coding: MolDX: Molecular Testing for Solid Organ Allograft RejectionExternal Website

L37348External Website

MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels

12/3/18

11/30/20

12/14/20

Active

Group 1: 87631, 87636, 87637, 0240U, 0241U

Group 2: 87632, 87633, 0098U, 0099U, 0100U, 0115U, 0151U, 0202U, 0223U, 0225U

A56974 – Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral PanelsExternal Website

L37907External Website

MolDX: myPath Melanoma Assay

6/3/19

10/31/19

3/25/20

Active

81479, 0090U

A56878 – Billing and Coding: MolDX: myPath Melanoma AssayExternal Website

L38067External Website

MolDX: Next-Generation Sequencing for Solid Tumors

2/10/20

3/5/20

3/12/20

Active

81445, 81479

A57870 – Billing and Coding: MolDX: Next-Generation Sequencing for Solid TumorsExternal Website

L38070External Website

MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

2/10/20

3/5/20

3/12/20

Active

81450, 81479

A57873 – Billing and Coding: MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid MalignanciesExternal Website

L35442External Website

MolDX: NRAS Genetic Testing

10/1/15

11/28/19

1130/20

Active

81311, 81479

A56998 – Billing and Coding: MolDX: NRAS Genetic TestingExternal Website

L36951External Website

MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health®)

3/6/17

11/28/19

11/21/20

Active

0045U

A56887 – Billing and Coding: MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)External Website

L36908External Website

MolDX: Percepta® Bronchial Genomic Classifier

3/13/17

11/28/19

11/30/20

Active

81479

A56972 – Billing and Coding: MolDX: Percepta® Bronchial Genomic ClassifierExternal Website

L38394External Website

MolDX: Pharmacogenomics Testing

8/3/20

8/3/20

6/12/20

Active

81220, 81225, 81226, 81227, 81231, 81232, 81247, 81283, 81306, 81328, 81335, 81350, 81355, 81374, 81377, 81381, 81383, 81406, 0030U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U

A58324 - Billing and Coding: MolDX: Pharmacogenomics TestingExternal Website

L38111External Website

MolDX: Pigmented Lesion Assay

3/30/20

NA

2/5/20

Active

0089U

A57915 - Billing and Coding: MolDX: Pigmented Lesion AssayExternal Website 

L38065External Website 

MolDX: Plasma-Based Genomic Profiling in Solid Tumors

7/27/20

NA

6/4/20

Active

81445, 81479

A57917 - Billing and Coding: MolDX: Plasma-Based Genomic Profiling in Solid TumorsExternal Website 

L38284External Website 

MolDX: Predictive Classifiers for Early Stage Non-small Cell Lung Cancer

7/27/20

NA

6/4/20

Active

81479

A58038 - Billing and Coding: MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung CancerExternal Website 

L36002External Website

MolDX: Prolaris® Prostate Cancer Genomic Assay

10/5/15

11/7/19

7/13/20

Active

81541

A57303 – Billing and Coding: MolDX: Prolaris™ Prostate Cancer Genomic AssayExternal Website 

L37142External Website

MolDX: Prolaris® Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease

7/10/17

6/4/20

5/26/20

Active

81541

A56925 – Billing and Coding: MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk DiseaseExternal Website

L37352External Website

MolDX: Prometheus IBD sgi Diagnostic Policy

11/6/17

2/25/21

2/25/21

Active

81479, 82397, 83520, 86140

A56940 – Billing and Coding: MolDX: Prometheus IBD sgi Diagnostic PolicyExternal Website

L38059External Website

MolDX: Prospera

3/10/20

12/24/20

12/18/20

Active

81479

A57859 – Billing and Coding: MolDX: Prospera™External Website

L38303External Website

MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease

11/9/20

NA

9/14/20

Active

81541, 81542, 0047U

A58371 - Billing and Coding: MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized DiseaseExternal Website

L38288External Website 

MolDX: Repeat Germline Testing

6/7/20

NA

4/17/20

Active

81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81161, 81162, 81163, 81164, 81165, 81166, 81167, 81171, 81172, 81173, 81174, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81200, 81201, 81202, 81203, 81204, 81205, 81209, 81212, 81215, 81216, 81217, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81232, 81233, 81234, 81238, 81239, 81240, 81241, 81242, 81243, 81244, 81247, 81248, 81249, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81269, 81271, 81274, 81283, 81284, 81285 81286, 81288, 81289, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81306, 81312, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81328, 81329, 81330, 81331, 81332, 81333, 81335, 81336, 81337, 81340, 81341, 81342, 81343, 81344, 81345, 81346, 81350, 81355, 81361, 81362, 81363, 81364, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81420, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81442, 81443, 81448, 81460, 81465, 81470, 81471

A57141 - Billing and Coding: MolDX: Repeat Germline TestingExternal Website

L38053External Website

MolDX: TruGraf Blood Gene Expression Test

12/30/19

12/24/20

12/18/20

Active

81479

A57446 – Billing and Coding: MolDX: TruGraf Blood Gene Expression TestExternal Website

L36021External Website

Molecular Diagnostic Tests (MDT)

10/1/15

12/19/19

11/30/20

Active

Group 1: 81105, 81106, 81107 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81161 - 81364 81400, 81402, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81413 - 81595 81599, 84999, 85999, 86152, 86153, 86849, 87999, 88341, 88342, 88360, 88361, 0004M, 0006M, 0007M, 0011M, 0012M, 0013M, 0001U, 0003U, 0005U, 0009U, 0012U, 0013U, 0014U, 0016U, 0017U, 0018U, 0019U, 0021U, 0022U, 0023U, 0024U, 0026U, 0027U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0039U, 0040U, 0045U – 0050U 0053U – 0060U 0062U, 0067U, 0068U, 0070U – 0076U, 0078U – 0080U 0083U, 0084U, 0087U – 0092U 0094U, 0101U – 0103U 0105U, 0107U, 0108U, 0111U, 0113U, 0114U, 0118U, 0120U, 0129U – 0132U, 0134U – 0138U, 0153U - 0162U

Group 2: 81401, 81403, 81406, 81407, 81412, 81443, 81445, 81479

Click to expand the full list of related policy articles

A55716 – Billing and Coding: MolDX: Abbott RealTime IDH1 and IDH2 testing for Acute Myeloid Leukemia (AML) External Website

A54243 – Billing and Coding: MolDX: CHD7 Gene Analysis GuidelinesExternal Website

A54241 – Billing and Coding: MolDX: 4q25-AF Risk Genotype GuidelinesExternal Website

A54242 – Billing and Coding: MolDX: 9p21 Genotype Test External Website

A54185 – Billing and Coding: MolDX: Afirma™ Assay by Veracyte UpdateExternal Website

A54186 – Billing and Coding: MolDX: AlloMap External Website

A54244 – Billing and Coding: MolDX: ApoE Genotype External Website

A54685 – Billing and Coding: MolDX: Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) Testing Coding and Billing GuidelinesExternal Website

A54253 – Billing and Coding: MolDX: Aspartoacyclase 2 Deficiency(ASPA) Testing External Website

A54254 – Billing and Coding: MolDX: ATP7B Gene Tests External Website

A54187 – Billing and Coding: MolDX: Avise PG AssayExternal Website

A54255 – Billing and Coding: MolDX: BCKDHB Gene Test External Website

A54188 – Billing and Coding: MolDX: bioTheranostics Cancer TYPE ID® External Website

A54256 – Billing and Coding: MolDX: BLM Gene Analysis External Website

A54257 – Billing and Coding: MolDX: BluePrint® TestExternal Website

A56307 – Billing and Coding: MolDX: ClonoSEQ® Assay for Assessment of Minimal Residual Disease (MRD) in Patients with Specific Lymphoid MalignanciesExternal Website

A54189 – Billing and Coding: MolDX: cobas® EGFR Mutation Test GuidelinesExternal Website

A54262 – Billing and Coding: MolDX: ENG and ACVRL1 Gene Tests External Website

A54263 – Billing and Coding: MolDX: FANCC Genetic Testing External Website

A54191 – Billing and Coding: MolDX: FDA-Approved BRAF TestsExternal Website

A54192 – Billing and Coding: MolDX: FDA-Approved EGFR TestsExternal Website

A54688 – Billing and Coding: MolDX: FDA-Approved KRAS TestsExternal Website

A54264 – Billing and Coding: MolDX: Fragile X External Website

A54265 – Billing and Coding: MolDX: GBA Genetic Testing External Website

A54266 – Billing and Coding: MolDX: HAX1 Gene Sequencing External Website

A54267 – Billing and Coding: MolDX: HBB Gene Tests External Website

A54193 – Billing and Coding: MolDX: HERmark® Assay by Monogram External Website

A54268 – Billing and Coding: MolDX: HEXA Gene Analysis External Website

A54269 – Billing and Coding: MolDX: HTTLPR Gene Testing External Website

A54270 – Billing and Coding: MolDX: IKBKAP Genetic Testing External Website

A54271 – Billing and Coding: MolDX: Immunohistochemistry (IHC) Indications for Breast PathologyExternal Website

A54272 – Billing and Coding: MolDX: KIF6 Genotype External Website

A54273 – Billing and Coding: MolDX: know error® External Website

A54274 – Billing and Coding: MolDX: L1CAM Gene Sequencing GuidelinesExternal Website

A54275 – Billing and Coding: MolDX: LPA-Aspirin Genotype External Website

A54276 – Billing and Coding: MolDX: LPA-Intron 25 Genotype External Website

A54194 – Billing and Coding: MolDX: MammaPrint External Website

A54277 – Billing and Coding: MolDX: MCOLN1 Genetic Testing GuidelinesExternal Website

A54278 – Billing and Coding: MolDX: MECP2 Genetic Testing External Website

A54288 – Billing and Coding: MolDX: Mitochondrial Nuclear Gene Tests GuidelinesExternal Website

A54209 – Billing and Coding: MolDX: MMACHC Test External Website

A56973 – Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)External Website

A54290 – Billing and Coding: MolDX: myPap™ External Website

A54291 – Billing and Coding: MolDX: NSD1 Gene Tests External Website

A54292 – Billing and Coding: MolDX: OncoCee™ External Website

A54195 – Billing and Coding: MolDX: Oncotype DX® Breast Cancer Assay External Website

A54196 – Billing and Coding: MolDX: Oncotype DX® Colon Cancer GuidelinesExternal Website

A54293 – Billing and Coding: MolDX: PAX6 Gene Sequencing GuidelinesExternal Website

A54295 – Billing and Coding: MolDX: PIK3CA Gene TestsExternal Website

A54296 – Billing and Coding: MolDX: PreDx®External Website

A54197 – Billing and Coding: MolDX: Progensa® PCA3 Assay Coverage UpdateExternal Website

A54297 – Billing and Coding: MolDX: PTCH1 Gene TestingExternal Website

A54198 – Billing and Coding: MolDX: ResponseDX Tissue of Origin® External Website

A54299 – Billing and Coding: MolDX: RPS19 Gene Tests External Website

A54300 – Billing and Coding: MolDx: SEPT9 Gene Test External Website

A54285 – Billing and Coding: MolDX: SMPD1 Genetic Testing External Website

A54284 – Billing and Coding: MolDX: STAT3 Gene Testing External Website

A54283 – Billing and Coding: MolDX: SULT4A1 Genetic Testing External Website

A54901 – Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Next Generation Sequencing Testing in CancerExternal Website

A54282 – Billing and Coding: MolDX: TERC Gene Tests External Website

A54199 – Billing and Coding: MolDX: Therascreen® EGFR RGQ PCR Kit GuidelinesExternal Website

A54200 – Billing and Coding: MolDX: therascreen® KRAS PCR Kit GuidelinesExternal Website

A54281 – Billing and Coding: MolDX: TP53 Gene Test External Website

A54201 – Billing and Coding: MolDX: Vectra™ DAExternal Website

A54279 – Billing and Coding: MolDx: VEGFR2 Tests External Website

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved