Regence Medicare Advantage Policy Manual TOPIC: Vectra™ DA Test for Monitoring Disease Activity in Rheumatoid Arthritis Section: Medicare Manual – Laboratory Approval Date: June 2014 Policy No: M-LAB67 Published Date: 01/01/2015 IMPORTANT REMINDER: The health plan’s Medicare Advantage Medical Policies are developed to provide guidance for members and providers regarding coverage in accordance with the member Evidence of Coverage (EOC) booklet. Benefit determinations are based in all cases on any applicable EOC language and any applicable CMS policy. To the extent there may be any conflict, applicable EOC language or applicable CMS policy take precedence over the health plan’s Medicare Advantage Medical Policy. MEDICARE MEDICAL POLICY CRITERIA CMS Coverage Manuals None National Coverage Determinations (NCD) None Noridian Healthcare Solutions (Noridian) Local Coverage Determinations (LCD) and Articles (LCA) None Non-Noridian Healthcare Solutions Local Coverage Determinations (LCD) and Articles (LCA) Note: This pathology test is performed solely by Crescendo Bioscience laboratory (California). In these circumstances, the health care plan is required to use coverage determinations published by the contractor assigned jurisdiction over the service area in which the tests are performed in accordance with Medicare compliance guidelines.(1) MolDX: Vectra DA Coding and Billing Guidelines (Published by Palmetto GBA, and applies to all states covered by the health care plan) 1 – M-LAB67 REFERENCES 1. Medicare Managed Care Manual, Chapter 4 - Benefits and BeneficiaryProtections, §90.2.1 2. Noridian LCD for Molecular Diagnostic Tests (MDT) (L33541) 3. noridianmedicare.com “Molecular Diagnostic Services Program (MolDX)” CROSS REFERENCES None CODES NUMBER DESCRIPTION It has been reported that for other payers, it might be submitted using multiple units of code 83520 (Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified) and a unit of 86140 (C-reactive protein). 83520 Immunoassay for analyte other than infectious agent antibody or CPT infectious agent antigen; qualitative or semiquantitative, multiple step method; quantitative, not otherwise specified 84999 Unlisted chemistry procedure 86140 C-reactive protein HCPCS 2 – M-LAB67
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