Molecular Pathology Procedures Reminder
National Government Services has been receiving many claims submitted for redetermination that were submitted for Group 3 Molecular Pathology Procedures.
The Group 3 codes from LCD (L35000/A56199) are identified as Tier 1 Noncovered Codes for which genetic testing is unlikely to impact therapeutic decision-making in the clinical management of the patient. These services are never payable by Medicare, and are automatically denied as not medically necessary when submitted, nor are they payable upon appeal.
We ask providers to refrain from submitting unnecessary appeal requests for these Group 3 Tier 1 Noncovered Codes as they will not lead to any change in adjudication. The CPT codes included in Medical Policy Article A56199: Billing and Coding: Molecular Pathology Procedures are listed here, and available in the article:
| Group 3 Tier 1 Noncovered Codes (A56199) | |||||
|---|---|---|---|---|---|
| 81105-81112 | 81161 | 81171-81174 | 81200-81205 | 81228-81232 | 81234 |
| 81238-81244 | 81247-81255 | 81257-81260 | 81269 | 81271 | 81274 |
| 81283-81286 | 81289-81291 | 81302-81304 | 81324-81331 | 81336-81337 | 81346 |
| 81349-81350 | 81355 | 81361-81364 | 81410-81417 | 81420 | 81422 |
| 81425-81427 | 81430-81440 | 81442-81443 | 81448 | 81455 | 81460 |
| 81465 | 81470-81471 | 81493 | 81500 | 81503-81504 | 81507 |
| 81521 | 81525 | 81535-81536 | 81538 | 81540-81541 | 81551 |
If you believe any of the coverage information should be updated based on clinical data, you may submit a LCD Reconsideration to begin the discussion of a potential policy revision.
Submitting appeal requests for all of a claim type that denies will not lead to policy change and will incur a greater expense for practices.
Posted 3/29/2022