Description

Tumor markers are substances normally produced in low quantities by cells in the body. Detection of a higher-than-normal serum level by radioimmunoassay or immunohistochemical techniques usually indicates the presence of a certain type of cancer. Currently, the main use of tumor markers is to assess a cancer’s response to treatment and to check for recurrence. In some types of cancer, tumor marker levels may reflect the extent or stage of the disease and can be useful in predicting how well the disease will respond to treatment.

Criteria

Prostate Specific Antigen (PSA)
PSA may be considered medically necessary for ANY of the following:

• Staging; or
• Monitoring response to therapy; or
• Detecting disease recurrence.

PSA for any other condition not stated above is considered not medically necessary.

Procedure Codes

Alpha-fetoprotein (AFP) Serum

AFP serum may be considered medically necessary for EITHER of the following:

• Serial measurements of AFP to diagnose germ cell tumors in individuals with adenocarcinoma, or carcinoma not otherwise specified, involving mediastinal nodes; or the diagnosis and monitoring of hepatocellular carcinoma; or
• Serial measurements of AFP and human chorionic gonadotropin (HCG) together to diagnose and monitor testicular cancer.

AFP for any other condition not stated above is considered not medically necessary.

Procedure Codes

Carcinoembryonic Antigen (CEA)

CEA may be considered medically necessary for ANY of the following:

• As a preoperative prognostic indicator with known colorectal carcinoma or mucinous appendiceal carcinoma when it will assist in staging and surgical treatment planning; or
• To detect asymptomatic recurrence of colorectal cancer after surgical and/or medical treatment for the diagnosis of colorectal cancer (not as a screening test for colorectal cancer); or
• To monitor response to treatment for metastatic cancer.

CEA for any other condition not stated above is considered not medically necessary.

Procedure Codes

CA 125

CA 125 may be considered medically necessary when reported for individuals with symptoms suggestive of ovarian cancer or in those with known ovarian cancer. It may be considered medically necessary for individuals with carcinomas of the fallopian tube, endometrium, and endocervix and may be associated with the presence of a malignant mesothelioma, as well as primary peritoneal carcinoma and metastatic adenoma cancer of unknown origin in the peritoneum.

CA 125 is not indicated for diagnosing or screening technique. Therefore, no payment can be made to rule out the covered diagnoses for these markers.

CA 125 for any other condition not stated above is considered not medically necessary.

Procedure Codes

CA 27.29 or CA 15-3

CA 27.29 or CA 15-3 may be considered medically necessary when reported for use in the management of individuals with breast cancer. CA 27.29 or CA 15-3 is considered not medically necessary for all other indications. The efficacy of these tests for all other indications has not been proven to change outcomes.

CA 27.29 or CA 15-3 is not indicated for diagnosing or screening technique. Therefore, no payment can be made to rule out the covered diagnoses for these markers.

CA 27.29 and CA 15-3 for any other condition not stated above is considered not medically necessary.

Procedure Codes

CA 19-9

CA 19-9 may be considered medically necessary when reported for monitoring response to treatment in patients with an established diagnosis of pancreatic and biliary ductal carcinoma. This test is not indicated for making the diagnosis of pancreatic or biliary cancer.

CA 19-9 is not indicated for diagnosing or screening technique. Therefore, no payment can be made to rule out the covered diagnoses for these markers.

CA 19-9 for any other condition not stated above is considered not medically necessary.

Procedure Codes

Serum Calcitonin (CT)

Ct is a tumor marker essential for the diagnosis and follow-up of medullary thyroid cancer. Calcitonin serum test may be considered medically necessary for the diagnosis and management of medullary thyroid cancer.

CT is considered experimental/investigational and, therefore, non-covered for any other indication other than listed above. Scientific evidence does not support its use for any other indication.

Procedure Codes

Thyroglobulin Testing (Tg)

Tg levels in the blood can be used as a tumor marker for certain kinds of thyroid cancer (particularly papillary or follicular thyroid cancer). Tg is not produced by medullary or anaplastic thyroid carcinoma. Tg testing may be considered medically necessary for the diagnosis and management of thyroid cancer.

A thyroglobulin antibody (TgAb) test is typically ordered along with the thyroglobulin test to determine the validity of the thyroglobulin testing and may be considered medically necessary.

Tg testing and TgAb are considered experimental/investigational and, therefore, non-covered for any other cancer diagnoses. Scientific evidence does not support its use for any other indication except what is stated above.

Procedure Codes

Chromogranin A (CgA)

CgA may be considered medically necessary only in the evaluation of suspected or known neuroendocrine tumors, including carcinoid, neuroblastoma and in the assessment of disease progression and treatment efficacy for these conditions. When reported for conditions other than neuroendocrine tumors, CgA is considered experimental/investigational, and therefore, non-covered.

Scientific evidence does not support its use for any other indication except what is stated above.

Immunoassay for tumor antigen; other antigen, quantitative, (e.g., CA 50, 72-4, 549) represents immunoassays for tumor antigens other than CgA that are not designated with a specific procedure code.

When reported for tumor antigen other than CgA, will be denied as experimental/investigational and, therefore, non-covered for cancer diagnoses and will be denied as not medically necessary for any nonmalignant diagnosis. In addition, when performed for asymptomatic individuals, tumor markers are considered screening.

Procedure Codes

Screening for Lung Cancer

Early cancer detection test (CDT)-Lung for detection of lung cancer is considered experimental/investigational and therefore, non-covered. Scientific evidence does not support its use for early detection.

Procedure Codes

Human Epididymis Protein 4 (HE4) Testing

The HE4 enzyme immunometric assay (EIA) for the quantitative determination of HE4 in human serum is considered experimental/investigational and, therefore, non-covered. Scientific evidence does not support its use for any indication.

Procedure Codes

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code 86304

Covered Diagnosis Codes for Procedure Code 86300

Covered Diagnosis Codes for Procedure Code 86301

Covered Diagnosis Codes for Procedure Code 86316

Covered Diagnosis Codes for Procedure Codes 82308, 84432, and 86800

Covered Diagnosis Codes for Procedure Codes 84152, 84153 and 84154

Covered Diagnosis Codes for Procedure Code 82378

Covered Diagnosis Codes for Procedure Codes 82105 and 84702

Non-covered Diagnosis Codes for Procedure Code 84999

Links

References (PDF)