National Coverage Determination 190.3 – Cytogenetic Testing: Discretionary Diagnoses
Under NCD 190.3, Cytogenetic Testing, CMS allows contractors discretion in coverage of specific Indications. “As this policy indicates, individual A/B MACs within their respective jurisdictions have the discretion to make coverage determinations they deem reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act.”
We reviewed this NCD and have determined the discretionary diagnoses in the table below are payable.
Discretionary Diagnoses for NCD 190.3 – Cytogenetic Studies
| ICD-10 Codes | Description |
|---|---|
| C81.01–C81.09 | Nodular lymphocyte predominant Hodgkin lymphoma |
| C81.11–C81.19 | Nodular sclerosis Hodgkin lymphoma |
| C81.21–C81.29 | Mixed cellularity Hodgkin lymphoma |
| C81.31–C81.39 | Lymphocyte depleted Hodgkin lymphoma |
| C81.41–C81.49 | Lymphocyte-rich Hodgkin lymphoma |
| C81.71–C81.79 | Other Hodgkin lymphoma |
| C81.91–C81.99 | Hodgkin lymphoma, unspecified |
| C82.00–C82.09 | Follicular lymphoma grade I |
| C82.11–C82.19 | Follicular lymphoma grade II |
| C82.21–C82.28 | Follicular lymphoma grade III, unspecified |
| C82.31–C82.39 | Follicular lymphoma grade IIIa |
| C82.41–C82.49 | Follicular lymphoma grade IIIb |
| C82.51–C82.59 | Diffuse follicle center lymphoma |
| C82.61–C82.69 | Cutaneous follicle center lymphoma |
| C82.81–C82.89 | Other types of follicular lymphoma |
| C82.91–C82.99 | Follicular lymphoma, unspecified |
| C83.11–C83.19 | Mantle cell lymphoma |
| C83.31–C83.39 | Diffuse large B-cell lymphoma |
| C83.51–C83.59 | Lymphoblastic (diffuse) lymphoma |
| C83.71–C83.79 | Burkitt lymphoma |
| C83.81–C83.89 | Other non-follicular lymphoma |
| C83.94 | Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of axilla and upper limb |
| C84.01–C84.09 | Mycosis fungoides |
| C84.11–C94.19 | Sezary disease |
| C84.41–C84.49 | Peripheral T-cell lymphoma, not classified |
| C84.61–C84.69 | Anaplastic large cell lymphoma, ALK-positive |
| C84.71–C84.79 | Anaplastic large cell lymphoma, ALK-negative |
| C84.91–C84.99 | Mature T/NK-cell lymphomas, unspecified |
| C85.11–C85.19 | Unspecified B-cell lymphoma |
| C85.21–C85.29 | Mediastinal (thymic) large B-cell lymphoma |
| C85.81–C85.89 | Other specified types of non-Hodgkin lymphoma |
| C85.91–C85.99 | Non-Hodgkin lymphoma, unspecified |
| C88.0 | Waldenstrom macroglobulinemia |
| C88.8 | Other malignant immunoproliferative diseases |
| C88.4 | Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT-lymphoma) |
| C90.00–C90.02 | Multiple myeloma |
| C90.10–C90.12 | Plasma cell leukemia |
| C90.20–C90.22 | Extramedullary plasmacytoma |
| C90.30–C90.32 | Solitary plasmacytoma |
| C91.10–C91.12 | Chronic lymphocytic leukemia of B-cell type |
| C91.30–C91.32 | Prolymphocytic leukemia of B-cell type |
| C91.40–C91.42 | Hairy cell leukemia |
| C91.50–C91.52 | Adult T-cell lymphoma/leukemia (HTLV-1-associated) |
| C91.60–C91.62 | Prolymphocytic leukemia of T-cell type |
| C91.A0–C91.A2 | Mature B-cell leukemia Burkitt-type not having achieved remission |
| C91.90–C91.92 | Lymphoid leukemia, unspecified |
| C91.Z0–C91.Z2 | Other lymphoid leukemia |
| C92.30–C92.32 | Myeloid sarcoma |
| C92.90–C92.92 | Myeloid leukemia, unspecified |
| C92.Z0–C92.Z2 | Other myeloid leukemia |
| C93.90–C93.92 | Monocytic leukemia, unspecified |
| C93.Z0–C93.Z2 | Other monocytic leukemia |
| C94.30–C94.32 | Mast cell leukemia |
| C94.40–C94.42 | Acute panmyelosis with myelofibrosis |
| C94.80–C94.82 | Other specified leukemias |
| C95.10–C95.12 | Chronic leukemia of unspecified cell type |
| C95.90–C95.92 | Leukemia, unspecified |
| C96.0 | Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis |
| C96.21–C96.29 | Malignant mast cell tumor |
| C96.4 | Sarcoma of dendritic cells (accessory cells) |
| C96.9 | Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified |
| C96.A | Histiocytic sarcoma |
| C96.Z | Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue |
| D05.91 | Unspecified type of carcinoma in situ of right breast |
| D05.92 | Unspecified type of carcinoma in situ of left breast |
| D45 | Chronic leukemia of unspecified cell type, in relapse |
| D47.01 | Cutaneous mastocytosis |
| D47.02 | Systemic mastocytosis |
| D47.1 | Chronic myeloproliferative disease |
| D47.2 | Leukemia, unspecified, in relapse |
| D47.3 | Essential (hemorrhagic) thrombocythemia |
| D47.4 | Osteomyelofibrosis |
| D47.9 | Neoplasm of uncertain behavior of lymphoid, hematopoietic and related tissue, unspecified |
| D47.Z1 | Post-transplant lymphoproliferative disorder (PTLD) |
| D47.Z9 | Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue |
| D60.0 | Chronic acquired pure red cell aplasia |
| D60.1 | Transient acquired pure red cell aplasia |
| D60.8 | Other acquired pure red cell aplasias |
| D60.9 | Acquired pure red cell aplasia, unspecified |
| D61.01 | Constitutional (pure) red blood cell aplasia |
| D61.09 | Other constitutional aplastic anemia |
| D61.818 | Other pancytopenia |
| D61.82 | Myelophthisis |
| D61.89 | Other specified aplastic anemias and other bone marrow failure syndromes |
| D61.9 | Aplastic anemia, unspecified |
| D64.0 | Hereditary sideroblastic anemia |
| D64.1 | Secondary sideroblastic anemia due to disease |
| D64.2 | Secondary sideroblastic anemia due to drugs and toxins |
| D64.3 | Other sideroblastic anemias |
| D64.4 | Congenital dyserythropoietic anemia |
| D64.9 | Anemia, unspecified |
| D69.6 | Thrombocytopenia, unspecified |
| D70.4 | Cyclic neutropenia |
| D70.8 | Other neutropenia |
| D70.9 | Neutropenia, unspecified |
| D72.818 | Other decreased white blood cell count |
| D72.819 | Decreased white blood cell count, unspecified |
| D72.820 | Lymphocytosis (symptomatic) |
| D72.821 | Monocytosis (symptomatic) |
| D72.822 | Plasmacytosis |
| D72.824 | Basophilia |
| D72.828 | Other elevated white blood cell count |
| D75.81 | Myelofibrosis |
Reviewed 8/28/2024