ModifiedBlue Cross Blue Shield - MassachusettsPolicy 139

Complete blood count (CBC) / Hemogram and related laboratory tests

This policy governs medical necessity and coverage for CBC/hemogram and several common laboratory tests (thyroid function tests, urine culture, PT/INR, serum iron studies) for commercial Blue Cross Blue Shield - Massachusetts members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyComplete blood count (CBC) / Hemogram and related laboratory tests

Policy CodePolicy 139

Change TypeMaterial pediatric coverage additions

Effective Date

Next Review Date

Key ActionBill pediatric CBC anemia screening with CPT 85027 and ferritin screening with CPT 82728 as specified to obtain coverage.

SourceLink

POLICY UPDATE CHANGES

Children ages 0-4 are covered for anemia screening when billed with 85027 under complete blood count.

Children ages 0-3 are covered for serum ferritin for anemia screening when billed with 82728.

Thyroid testing description clarified.

6+test categories

Screening excludedscreening excluded

Conditionalrepeat testing guidance

2pediatric edits

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Coverage Criteria and Medical Necessity

CBC / Hemogram Medical Necessity Criteria

Covered when indications consistent with clinical signs, symptoms, or conditions that could reasonably be associated with hematologic abnormalities are present.

CBC/Hemogram general indications: Evaluation of bone marrow dysfunction due to neoplasm, therapeutic agents, exposure to toxins, or pregnancy; assessment of peripheral destruction of blood cells; suspected bone marrow failure or infiltrate; suspected myeloproliferative, myelodysplastic, or lymphoproliferative processes; and immune disorders.

RBC-related indications: Signs, symptoms, or test results associated with anemia or polycythemia (examples: pallor, weakness, fatigue, bleeding or suspected blood loss, abnormal menstrual bleeding, hematuria, hematemesis, positive fecal occult blood test, malnutrition, vitamin deficiency, malabsorption, known malignancy, dyspnea, angina, splenomegaly, hepatomegaly, jaundice, growth retardation, nailbed deformities).

WBC-related indications: Signs, symptoms, or test results associated with infection, inflammation, leukemia, bone marrow failure/infiltrate, drug effects causing leukopenia/leukocytosis, or immune disorders (examples: fever, chills, sweats, sepsis, focal infection signs, opportunistic infections, altered consciousness, pain, hepatomegaly, splenomegaly, lymphadenopathy).

Platelet-related indications: Signs, symptoms, or test results associated with platelet production, destruction, or dysfunction (examples: bleeding, ecchymosis, purpura, petechiae, thrombosis, DIC, heparin therapy, neonatal maternal ITP, massive transfusion, cardiopulmonary bypass, HUS, renal disease, splenomegaly, autoimmune disorders).

Thyroid Function Tests

Thyroid function testing covered when clinically indicated for diagnosis or monitoring of thyroid disease or related conditions.

Thyroid testing indications: Distinguish primary vs secondary hypothyroidism; confirm or rule out primary hypo- or hyperthyroidism; monitor thyroid hormone levels for goiter, nodules, thyroid cancer, or drug therapy; follow-up testing for malignant endocrine neoplasm or long-term thyroid drug therapy; medically necessary for thyroid/endocrine disease, metabolic disorders, malnutrition, certain anemias, psychiatric disorders, cardiac arrhythmias, menstrual disorders, and a wide array of signs and symptoms listed in the policy.

Testing asymptomatic patients without suspicion of thyroid dysfunction is screening and not covered.

Urine Culture

Bacterial urine culture covered when clinical or laboratory evidence suggests urinary tract infection or when evaluating suspected systemic infection with possible urinary source.

Urine culture indications: Abnormal urinalysis suggesting UTI (pyuria, bacteriuria, positive leukocyte esterase or nitrite, hematuria), clinical signs/symptoms of UTI (urgency, frequency, dysuria, suprapubic or flank pain, fever/chills), evaluation of suspected urosepsis or systemic infection without known source, test-of-cure in complicated infections, preoperative evaluation in select genitourinary surgeries (e.g., prior to renal transplantation, manipulation/removal of kidney stones, transurethral surgery), and detection of occult infection in renal transplant recipients on immunosuppression.

Urinalysis is common practice prior to culture but culture may be performed when clinical presentation justifies it; routine screening of asymptomatic patients is not covered.

Prothrombin Time (PT)

Prothrombin Time (PT)/INR testing covered when used to assess coagulation status in relevant clinical contexts.

PT indications: Monitoring patients on warfarin; assessing patients with signs or symptoms of abnormal bleeding or thrombosis; evaluating conditions associated with extrinsic pathway abnormalities (e.g., liver disease, vitamin K deficiency, factor deficiencies, DIC, malignancy, organ transplantation); and pre-procedural evaluation when history or signs suggest coagulopathy.

PT expressed in seconds and/or INR; PT is not generally useful for monitoring heparin therapy.

PT frequency/limits: Repeat testing frequency should be determined by changes in underlying medical condition or warfarin dosing. For a patient on stable warfarin therapy, it is ordinarily not necessary to repeat testing more than every 2–3 weeks. Do not repeat after a normal test unless there is a change in clinical status. Routine screening of asymptomatic patients is not covered.every 2-3 weeks for stable warfarin

Serum Iron Studies

Serum iron studies covered when evaluating anemia or iron disorders.

Iron studies indications: Ferritin, serum iron, TIBC (or transferrin) used to evaluate patients with suspected iron deficiency or iron overload; appropriate when assessing anemia, disorders of iron metabolism, toxic metal exposure, and for monitoring response to therapy.

Ferritin and transferrin are acute phase reactants and may be affected by inflammation or illness; fasting morning specimen preferred.

Iron studies - medically necessary indications

Serum iron studies (ferritin, iron, TIBC/transferrin) are covered when used to diagnose or manage iron deficiency or overload and when results may alter management.

Clinical indications for iron studies: Indications include abnormal blood count values (decreased MCV, low/normal MCV with low Hgb/Hct, increased RDW), pica, acute or chronic GI blood loss, hematuria, menorrhagia, malabsorption, post-gastrectomy or gastrojejunostomy, malnutrition, preoperative autologous blood collection, chronic inflammatory or malignant conditions that mimic iron deficiency, post significant surgery with blood loss and inadequate iron replacement, chronic renal disease (monitoring), and evaluation of toxic iron/metal exposure.

Follow-up testing appropriate to monitor response to therapy; if ferritin normal, repeat ferritin ordinarily not necessary unless clinical status changes.

Operational notes for iron studies: Do not routinely order both transferrin and TIBC concurrently; it is not ordinarily necessary to measure both iron/TIBC (or transferrin) and ferritin in initial testing. Ferritin is useful to initiate and monitor treatment for iron overload.

Best performed fasting in the morning and after abstention from medications that influence iron balance.

Acute Hepatitis Panel - medically necessary indications

Acute Hepatitis Panel is covered for diagnostic evaluation of suspected viral hepatitis and certain pre/post-transplant assessments.

Hepatitis panel indications: Indicated to detect viral hepatitis when liver function tests are abnormal or when symptoms of hepatitis are present; used for differential diagnosis of liver disease and prior to and subsequent to liver transplantation. Positive HCV antibody often requires confirmatory testing. Panel not indicated for routine screening for HBV or HCV or to assess prior vaccination against HAV or HBV.

If exposure timing is uncertain and symptoms persist despite a negative panel, repeat testing approximately 2 weeks to 2 months may be indicated.

Limitations and repeat testing

Testing limitations and repeat testing rules

Repeat testing criteria: Repeat testing is based on changes in the patient's condition or therapy (e.g., warfarin dosing). For stable warfarin therapy, repeat PT/INR ordinarily not more than every 2–3 weeks. Repeat ferritin is ordinarily not necessary if previously normal unless the patient's condition changes. Do not repeat tests after normal results unless clinical status changes. Routine screening of asymptomatic patients is not covered.every 2-3 weeks for stable warfarin

A negative hepatitis panel in the context of ongoing symptoms or uncertain exposure timing may warrant repeat testing in about 2 weeks to 2 months.

Medical necessity linkage for listed CPT codes

Coverage requires that CPT codes be submitted with an ICD-10 diagnosis code meeting the policy's medical necessity criteria and applicable NCDs.

General linkage requirement: CPT procedure codes listed in this policy are considered medically necessary for commercial members only when submitted with an ICD-10 diagnosis code that meets the policy's medical necessity criteria and relevant CMS National Coverage Determinations referenced in the document.

Claims submitted without an appropriate supporting ICD-10 diagnosis meeting medical necessity may be excluded from coverage.

Serum ferritin — pediatric coverage

Pediatric screening exception

Ferritin pediatric screening: Ferritin (CPT 82728) is covered for children ages 0–3 when billed for anemia screening. Additionally, CBC anemia screening (CPT 85027) is covered for children ages 0–4 when billed appropriately.ages 0-3 for ferritin; ages 0-4 for CBC anemia screening

Effective dates noted in policy history.

Acute hepatitis panel — required components

Hepatitis panel composition requirement

Acute hepatitis panel components: CPT 80074 must include Hepatitis A antibody (HAAb), IgM (86709); Hepatitis B core antibody (HBcAb), IgM (86705); Hepatitis B surface antigen (HBsAg) (87340); and Hepatitis C antibody (86803) to be considered the acute hepatitis panel.

General laboratory test coverage

Covered when consistent with clinical indications described in test-specific sections and applicable NCDs (see Endnotes).

General coverage logic: Laboratory tests (CBC, thyroid function, urine culture, PT/INR, serum iron studies, hepatitis panels) are covered when used to evaluate, diagnose, or monitor the clinical conditions detailed in the policy and ordered per standard clinical practice; coverage is guided by referenced National Coverage Determinations.

Pediatric anemia screening coverage

Pediatric screening exceptions

Pediatric CBC and ferritin screening: Children ages 0–4: CBC anemia screening covered when billed with CPT 85027. Children ages 0–3: serum ferritin (CPT 82728) covered when billed for anemia screening.age-based

Effective dates are listed in policy history.

Routine screening of patients who are asymptomatic is not a covered service. Tests performed solely for screening in patients without signs, symptoms, or a condition that could reasonably be expected to cause the target disorder may be denied as not medically necessary.

If the ordering provider specifically requests only hemoglobin (Hgb) or hematocrit (Hct), the remaining components of the CBC should not be ordered. Limit orders to the test(s) requested to avoid noncovered or duplicative CBC components.

The acute hepatitis panel is not indicated for routine screening of asymptomatic patients for Hepatitis B or C, nor is it intended to assess prior vaccination against Hepatitis A or B. The panel is intended for differential diagnosis of suspected viral hepatitis and related clinical evaluations; repeat or alternative testing and confirmatory assays should be used as clinically indicated.

Claims for the CPT procedure codes listed in this policy must be submitted with an appropriate ICD-10 diagnosis code that meets the policy's medical necessity criteria (and applicable NCD). Services billed without a supporting diagnosis that meets these requirements may be excluded from coverage.

When the initial hepatitis panel is completely negative but clinical concern persists and the timing of exposure or disease stage is uncertain, a repeat panel may be required approximately 2 weeks to 2 months later to exclude evolving infection. Once a diagnosis is established, ordering should shift to the specific individual tests needed for confirmation or monitoring.

Testing of patients who are asymptomatic, or who do not have a condition likely to cause a hematologic abnormality, is considered screening and is not covered. Order CBCs, iron studies, and related tests only when clinical signs, symptoms, or diagnostic findings indicate an expected hematologic abnormality.

Repeat testing without a change in the patient's clinical condition is ordinarily not medically necessary. For example, if a documented serum ferritin is normal, routine repeat ferritin testing is not indicated unless the patient’s condition changes or ongoing monitoring is clinically justified.

Coverage and indications for the tests in this policy are guided by referenced National Coverage Determinations (NCDs). Where applicable, the policy aligns covered diagnoses and medical necessity criteria with the cited NCDs referenced in the Endnotes.

Specific Covered Indications

inv-64: CBC/Hemogram for evaluation of red cell, white cell, and platelet disorders when clinical signs/symptoms or lab findings suggest an abnormality.

CBC/Hemogram used to evaluate red cell, white cell, and platelet disorders when clinical signs/symptoms or laboratory findings suggest an abnormality.

CBC indications summary: Use CBC/hemogram to evaluate suspected hematologic disorders (anemia, leukemia, polycythemia, thrombocytosis, thrombocytopenia), bone marrow dysfunction, peripheral destruction of blood cells, myeloproliferative/malignant processes, and to monitor treatment effects.

inv-65: Urine culture when urinalysis is abnormal or when clinical signs/symptoms suggest UTI or systemic infection.

Urinalysis is commonly performed prior to urine culture and often guides the need for culture.

Urinalysis before culture: An antecedent abnormal urinalysis (microscopic or biochemical findings suggestive of infection) commonly guides whether a urine culture is performed, though culture may be indicated based on clinical presentation even without prior urinalysis.

Testing Frequency and Repeat Testing Guidance

inv-78: PT/INR repeat interval — every 2-3 weeks

Recommended repeat intervalEvery 2–3 weeks for patients on stable warfarin therapy

Repeat after changeRepeat PT/INR sooner when there is a change in clinical status or warfarin dosing

No routine repeats after normal resultDo not repeat after a normal PT unless the patient's medical status changes

inv-79: Coagulation testing (context: warfarin monitoring) — ordinarily no more than every 2-3 weeks

Frequency for warfarin monitoringOrdinarily no more than every 2–3 weeks in a patient on stable warfarin therapy

Indication for testingPT/INR used to monitor warfarin effect and guide dosing adjustments

Codes (CPT, ICD-10) and Coding Notes

ICD-10-CM Diagnosis Codes referenced in this sectionICD-10

N96	Recurrent pregnancy loss
N97.0	Female infertility associated with anovulation
N97.1	Female infertility of tubal origin
N97.2	Female infertility of uterine origin
N97.8	Female infertility of other origin
N97.9	Female infertility, unspecified
Q90.0	Trisomy 21, nonmosaicism (meiotic nondisjunction)
Q90.1	Trisomy 21, mosaicism (mitotic nondisjunction)
Q90.2	Trisomy 21, translocation
Q90.9	Down syndrome, unspecified

1–10 of 81

1/9

ICD-10-CM Diagnosis Codes — additional metabolic / renal / obesityICD-10

E03.9	Hypothyroidism, unspecified
E05.00	Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm
E53.8	Deficiency of other specified B group vitamins
E63.9	Nutritional deficiency, unspecified
E66.01	Morbid (severe) obesity due to excess calories
E66.9	Obesity, unspecified
N18.30	Chronic kidney disease, stage 3 unspecified
N18.31	Chronic kidney disease, stage 3a
N18.32	Chronic kidney disease, stage 3b
Z98.84	Bariatric surgery status

Provider Billing, Ordering, and Documentation Actions

Documentation Required

Thyroid testing — diagnosis requirement

Thyroid testing CPT codes must be submitted with an appropriate ICD-10 diagnosis that meets medical necessity per NCD 190.22 and the policy's listed covered diagnoses. Ensure the claim includes a diagnosis that supports thyroid dysfunction, monitoring of known thyroid disease, or other listed clinical indications rather than routine screening of asymptomatic patients.

Submit CPT codes for thyroid testing with an ICD-10 diagnosis consistent with NCD 190.22 and policy indications
Testing of asymptomatic patients for routine thyroid screening is not a covered service

Documentation Required

Urine culture — diagnosis requirement

Urine culture CPT codes (e.g., 87086, 87088) must be submitted with an ICD-10 diagnosis that documents clinical signs, symptoms, or urinalysis findings consistent with a urinary tract infection or other indications in NCD 190.12 and the policy. Claims lacking an appropriate supporting diagnosis may be denied.

Order urine culture when urinalysis is abnormal or patient has clinical signs/symptoms of UTI per policy indications

Ordering and Test Preparation Requirements

Note

Urinalysis commonly performed before culture

Order a urinalysis prior to urine culture when clinically appropriate; culture may follow an abnormal urinalysis or when presentation is highly suggestive of UTI even without antecedent testing.

Note

Limited-order preference for CBC components

If only hemoglobin or hematocrit is requested by the ordering provider, do not order the remaining CBC components.

Prior Authorization

Precertification required for inpatient services

Precertification/preauthorization is required for inpatient services; outpatient prior authorization is generally not required for commercial outpatient services.

Services Not Covered / Exclusions

Routine screening tests in asymptomatic individuals are not covered. This includes routine thyroid testing or urine culture when patients have no signs or symptoms to suggest disease; such screening may be denied.

Routine screening is not covered for the acute hepatitis panel (not appropriate for HBV/HCV screening or to assess prior vaccination). Ordering duplicative or unnecessary full panels after a diagnosis is established may also be considered non-covered.

Tests billed without an appropriate supporting ICD-10 diagnosis that meets the policy’s medical necessity requirements (and relevant NCD criteria) may be denied for lack of medical necessity.

This excerpt does not list additional explicit test exclusions; overall coverage is informed by the National Coverage Determinations referenced in the Endnotes and by the medical necessity language within each test section.

Background and Rationale

A complete blood count (CBC) or hemogram evaluates red cell, white cell, and platelet parameters to detect and monitor hematologic disorders. Common clinical uses include assessing anemia, infection or inflammation, thrombocytopenia or thrombocytosis, bone marrow dysfunction or infiltrative processes, and monitoring treatment effects (e.g., cytotoxic therapy or transfusion). CBC results guide further diagnostic testing and management decisions.

Definitions and Test Components

inv-57: PT — Prothrombin Time (PT)

DefinitionProthrombin Time (PT) is a laboratory test used to detect bleeding or clotting disorders and to calculate the International Normalized Ratio (INR)

Clinical useAssesses extrinsic coagulation pathway and helps evaluate patients with suspected coagulopathy

Relation to INRPT expressed in seconds can be converted to INR to standardize results across laboratories

inv-58: Serum iron studies — ferritin, iron, iron binding capacity and transferrin used to evaluate anemia/iron disorders

ComponentsSerum iron studies include ferritin, serum iron, total iron binding capacity (TIBC), and transferrin

PurposeUsed to evaluate patients with anemia and disorders of iron metabolism (deficiency or overload)

Policy Revision History and Material Changes

2023-10-01policy_revisionLatest

Added pediatric CBC anemia screening coverage: children ages 0-4 covered when billed with CPT 85027.

2023-04-01policy_revision

Added pediatric serum ferritin screening coverage: children ages 0-3 covered when billed with CPT 82728.

2023-02clarification

Thyroid testing description clarified (non-material change).

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyComplete blood count (CBC) / Hemogram and related laboratory tests

Policy CodePolicy 139

Change TypeMaterial pediatric coverage additions

Effective Date

Next Review Date

Key ActionBill pediatric CBC anemia screening with CPT 85027 and ferritin screening with CPT 82728 as specified to obtain coverage.

SourceLink

On This Page

inv-66: PT/INR for warfarin monitoring and assessment of bleeding/thrombotic risk in appropriate clinical scenarios.

PT/INR testing covered for assessment of coagulation and warfarin monitoring in appropriate clinical scenarios.

PT/INR indications: Assessment and monitoring of patients on warfarin; evaluation of patients with signs or symptoms of bleeding or thrombosis; evaluation of conditions associated with extrinsic pathway abnormalities; and pre-procedural assessment when indicated by history or signs.

For patients on stable warfarin, repeat testing ordinarily not more than every 2–3 weeks.

inv-67: Thyroid function testing for diagnosis and monitoring of thyroid disease and related clinical conditions.

Thyroid function testing covered for diagnosis and monitoring of thyroid disease and related clinical conditions.

Thyroid testing indications summary: Use TSH with complementary free T4 or total T4 with T3 uptake to diagnose and follow thyroid disorders, distinguish primary vs secondary dysfunction, confirm or rule out hypothyroidism or hyperthyroidism, and monitor therapy or disease such as goiter, nodules, or thyroid cancer.

Testing asymptomatic patients without suspicion of thyroid dysfunction is screening and not covered.

inv-68: Serum iron studies for evaluation of anemia/iron disorders.

Serum iron studies covered for evaluation of anemia and iron disorders and for monitoring response to therapy.

Serum iron studies indications summary: Ferritin, serum iron, TIBC or transferrin used to evaluate iron deficiency and iron overload, in the context of abnormal blood counts, GI blood loss, menorrhagia, malabsorption, post-surgical states, chronic disease, transfusion history, or suspected toxic metal exposure; ferritin useful to initiate and monitor treatment for iron overload.

Do not routinely repeat ferritin if previously normal unless clinical status changes; fasting morning specimen preferred.

inv-69: Evaluation of iron deficiency or iron overload, and monitoring response to therapy for these conditions.

Evaluation of iron deficiency or iron overload, and monitoring response to therapy.

Iron disorder evaluation: Ferritin, iron and either iron binding capacity or transferrin are useful in differential diagnosis; follow-up testing may monitor response to therapy; ferritin useful to initiate/monitor treatment for iron overload.

Avoid routine simultaneous ordering of redundant tests (e.g., both transferrin and TIBC) unless clinically justified.

inv-70: Detection of acute viral hepatitis (A, B, C) when LFTs abnormal or symptoms present; pre/post liver transplantation.

Hepatitis panel used for detection of acute viral hepatitis (A, B, C) when liver enzymes are abnormal or symptoms are present, and for transplant evaluation.

Hepatitis panel indications summary: Use the acute hepatitis panel to detect viral hepatitis when LFTs are abnormal or symptoms of hepatitis are present; for differential diagnosis of liver disease; and prior to and following liver transplantation. Positive HCV antibody often requires confirmatory testing; repeat testing may be indicated 2 weeks to 2 months if exposure timing or stage is uncertain.

The panel is not indicated for routine screening for HBV or HCV or to assess prior vaccination against HAV or HBV.

inv-71: Various pregnancy supervision, infertility, endocrine, liver disease, substance dependence, obesity, CKD, and other listed diagnoses — CPT groups reference additional ICD-10 codes considered medically necessary.

Certain CPT groups reference additional ICD-10 diagnoses that are considered medically necessary when medical necessity criteria are met.

ICD-10 linkage to CPT groups: Specific CPT procedure groups (e.g., thyroid testing, urine culture, PT, iron studies, hepatitis panel) include lists of additional ICD-10 diagnosis codes in this policy that may be submitted to support medical necessity for commercial members when criteria are met.

References to relevant NCDs are provided in the document.

inv-72: Evaluation and diagnosis of hematologic disorders (anemia, leukemia, polycythemia, thrombocytosis, thrombocytopenia) and monitoring treatment effects.

Evaluation and diagnosis of hematologic disorders and monitoring of treatment effects.

Hematologic disorder evaluation: Use CBC/hemogram to evaluate anemia, leukemia, polycythemia, thrombocytosis, thrombocytopenia, and to monitor treatment effects or disease progression as clinically indicated.

inv-73: Diagnosis and follow-up of thyroid disorders using TSH and complementary free T4 or total T4 with T3 uptake.

Diagnosis and follow-up of thyroid disorders using TSH and complementary assays.

Thyroid diagnostic testing: Measure TSH and, when indicated, free T4 or total T4 with T3 uptake (and calculate free thyroxine index when necessary) to diagnose and follow thyroid dysfunction and to monitor therapy.

Additional tests may be necessary in complex cases or hospitalized patients where results may be skewed.

inv-74: Assessment of coagulation (PT/INR) including monitoring warfarin therapy.

Assessment of coagulation (PT/INR) including monitoring warfarin therapy.

Coagulation assessment: PT/INR assesses the extrinsic coagulation pathway and is used to monitor warfarin therapy, evaluate bleeding/clotting risk, and assess patients with conditions affecting vitamin K–dependent factors or liver synthesis.every 2-3 weeks for stable warfarin monitoring

Repeat testing guidance applies: ordinarily not more than every 2–3 weeks in stable warfarin therapy and not repeated after a normal test unless clinical status changes.

inv-75: Urine culture to establish probable etiology of presumed urinary tract infection; typically preceded by urinalysis.

Urine culture to establish probable etiology of presumed urinary tract infection; typically preceded by urinalysis.

Urine culture use: Urine culture is used to establish the probable etiology of presumed UTI and to guide antibiotic selection; an antecedent abnormal urinalysis often guides whether culture is performed, although culture may be indicated based on clinical presentation.

Isolates deemed significant may undergo identification and susceptibility testing as requested by the ordering physician.

inv-76: Hepatitis panel used for differential diagnosis of acute or chronic viral hepatitis (A, B, C) and for follow-up testing as clinically indicated.

Hepatitis panel used for differential diagnosis of acute or chronic viral hepatitis (A, B, C) and for follow-up testing as clinically indicated.

Hepatitis panel use: Use the acute hepatitis panel for differential diagnosis in patients with symptoms or abnormal LFTs, for transplant evaluation, and for follow-up testing; positive HCV antibody often requires confirmatory testing and repeat panel may be necessary when exposure timing is uncertain.

Panel composition requirements apply (see required components).

inv-77: Serum iron studies and ferritin for evaluation of iron deficiency or overload; ferritin useful to initiate and monitor treatment for iron overload.

Serum iron studies and ferritin for evaluation of iron deficiency or overload; ferritin useful to initiate and monitor treatment for iron overload.

Iron studies for deficiency/overload: Ferritin, iron, and either iron binding capacity or transferrin are useful in differential diagnosis of iron deficiency or overload; ferritin is specific for iron deficiency when low and useful to initiate and monitor treatment for iron overload.

Ferritin and transferrin are acute phase reactants and may be affected by inflammation; repeat ferritin not ordinarily necessary if normal unless clinical status changes.

When to test more oftenIncrease testing frequency when warfarin dosing or clinical status changes

inv-80: Ferritin repeat guidance — ordinarily not necessary if normal unless patient's condition changes

When repeat ferritin is neededRepeat ferritin ordinarily not necessary if prior result is normal unless the patient's condition changes and ferritin assessment is needed for ongoing management

Not for routine screeningFerritin testing is not indicated solely for routine screening of asymptomatic patients

Clinical triggers for repeatRepeat ferritin may be appropriate with new signs of iron disorder, ongoing blood loss, or changes in therapy

inv-81: Hepatitis panel repeat testing — guidance on timing for repeat after negative panel

When to repeat panelIf time of exposure or stage of disease is unknown and symptoms persist despite a completely negative initial panel, repeat the acute hepatitis panel approximately 2 weeks to 2 months later

Purpose of repeatRepeat testing helps exclude early infection when antibodies or antigens may not yet be detectable

Use targeted tests after diagnosisOnce diagnosis is established, order specific tests rather than repeating the full panel

Document urinalysis results, symptoms (dysuria, frequency, fever, flank pain, etc.), or other clinical rationale on the medical record and claim

Documentation Required

Hepatitis panel — panel composition and diagnosis requirement

The Acute Hepatitis Panel (CPT 80074) must include the specified component tests and be submitted with an ICD-10 diagnosis consistent with NCD 190.33 and the policy's listed indications (for example, abnormal LFTs, symptoms of hepatitis, or transplant evaluation). After a hepatitis diagnosis is established, order only the individual tests needed rather than repeating the full panel.

80074 must include: Hepatitis A IgM (86709), Hepatitis B core IgM (86705), Hepatitis B surface antigen (87340), Hepatitis C antibody (86803)
Submit CPT 80074 with ICD-10 diagnosis consistent with policy/NCD 190.33 (e.g., abnormal LFTs, symptoms of hepatitis, pre/post-transplant evaluation)
After a definitive hepatitis diagnosis, order only individual tests required for monitoring or management

Documentation Required

Clinical documentation for iron studies

Clinical documentation for iron studies should clearly support testing by documenting abnormal blood counts or clinical features that suggest iron deficiency or overload (for example, low MCV, low hemoglobin/hematocrit, increased RDW, pica, GI blood loss, menorrhagia, malabsorption, prior surgeries, chronic disease, or multiple transfusions). Repeat ferritin or other iron studies should be supported by a change in clinical status or when results would alter management.

Document specific abnormal CBC indices (MCV, Hgb/Hct, RDW) when ordering iron studies
Document signs/symptoms or history (pica, GI blood loss, menorrhagia, malabsorption, prior gastric surgery, transfusion history, chronic inflammatory disease) that indicate need for iron studies
Repeat testing requires documentation of change in condition or rationale for monitoring response to therapy

Documentation Required

Documentation for hepatitis panel

Documentation for ordering the hepatitis panel must include the clinical rationale such as abnormal liver function tests, signs or symptoms of hepatitis, known exposure timing, or transplant evaluation. If a positive antibody result requires confirmatory testing (for example, HCV), document the need for follow-up testing and timing.

Document abnormal LFTs or clinical signs/symptoms of hepatitis when billing 80074
Document timing of exposure or clinical course if relevant and rationale for repeat panel when initial panel is negative but suspicion persists
Document plan for confirmatory testing when initial antibody tests are positive (e.g., HCV confirmatory test)

Documentation Required

Pediatric ferritin screening documentation

Pediatric ferritin (CPT 82728) is covered for anemia screening in children ages 0–3 when billed appropriately. Claims for pediatric ferritin screening should include documentation that the test is being performed for anemia screening in the applicable age group.

Children ages 0–3: serum ferritin (82728) covered when billed for anemia screening
Include documentation indicating the screening purpose and the child’s age on the claim/medical record

Billing Rule

Ordering and billing requirements for providers

Tests should be ordered by a physician or authorized provider per standard practice; specific pediatric screening coverage requires billing with the listed CPT codes (85027 and 82728) for the indicated ages.

Ensure appropriate CPT and ICD-10 coding and documentation accompany claims for pediatric screening tests.

Interpretation noteFerritin is highly specific for iron deficiency; TIBC/transferrin and percent saturation aid differential diagnosis

inv-59: ferritin, iron, TIBC and transferrin — serum iron studies components

Listed componentsFerritin, serum iron, total iron binding capacity (TIBC) and transferrin comprise standard serum iron studies

Clinical utilityFerritin useful to initiate and monitor treatment for iron overload; low ferritin indicates iron deficiency

Ordering guidanceDo not routinely order both transferrin and TIBC or both iron/TIBC and ferritin unless clinically indicated

inv-60: Acute Hepatitis Panel components (HAAb IgM, HBcAb IgM, HBsAg, HCV antibody)

Panel componentsAcute Hepatitis Panel must include HAAb IgM (Hepatitis A antibody, IgM), HBcAb IgM (Hepatitis B core antibody, IgM), HBsAg (Hepatitis B surface antigen), and HCV antibody

CPT mappingCPT 80074 denotes the acute hepatitis panel and must contain the specified component tests

Use casePanel used for differential diagnosis of liver disease and pre/post-transplant assessments

inv-61: CBC — Complete blood count (CBC)

DefinitionComplete blood count (CBC) includes hemogram and differential and is used to evaluate red cells, white cells, and platelets

ComponentsIncludes hemoglobin, hematocrit, RBC, WBC, platelet count and red cell indices

Clinical roleUsed to diagnose and monitor anemia, leukemia, polycythemia, thrombocytosis, thrombocytopenia and treatment effects

inv-62: Thyroid testing — TSH, free T4 and related assays used to diagnose and follow thyroid dysfunction

Common assaysThyroid testing typically includes serum TSH and complementary free T4 or total T4 with T3 uptake

PurposeUsed to diagnose and follow thyroid dysfunction (hypo- and hyperthyroidism) and monitor therapy

Additional testsFree thyroxine index (FTI) or other assays may be used when protein-binding effects or complex cases require correction

inv-63: PT/INR — measures extrinsic coagulation pathway and monitors warfarin therapy

Definition and usePT/INR measures the extrinsic coagulation pathway and is used to monitor warfarin therapy

MeasurementPT reported in seconds and commonly standardized as INR for warfarin management

Monitoring guidanceTesting frequency based on clinical status and warfarin dosing; stable patients ordinarily tested every 2–3 weeks