CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB030

In Vitro Chemoresistance and Chemosensitivity Assays

This policy governs BCBSNM reimbursement for in vitro chemosensitivity and chemoresistance laboratory assays and applies to providers submitting claims to Blue Cross Blue Shield of New Mexico; plan documents and provider contracts may supersede this policy.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyIn Vitro Chemoresistance and Chemosensitivity Assays

Policy CodePolicy CPCPLAB030

Change TypeClarified (literature review)no material coverage change

Effective DateNov 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request; claims are subject to review and adjudication per plan documents and provider contracts.

SourceLink

POLICY UPDATE CHANGES

Document updated with literature review; reimbursement information unchanged.

2non-reimbursable assay types

~20example codes listed

1.0policy version

Nov 1, 2023plan effective

Coverage Criteria: Reimbursement Stance

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Non-reimbursable services

Reimbursement stance for listed assays:

In vitro chemosensitivity assays (including, but not limited to, the histoculture drug response assay or a fluorescent cytoprint assay) are not reimbursable.

In vitro chemoresistance assays (including, but not limited to, extreme drug resistance (EDR) assays) are not reimbursable.

Documentation, Claims, and Provider Responsibilities

Documentation Required

Documentation and claim review — submit accurate claims and respond to requests

Providers must submit accurate, appropriately coded claims and be prepared to provide additional documentation upon request; claims are subject to code-edit protocols and review against plan documents and provider contracts.

Submit claims using valid HIPAA-approved code sets and code combinations.
Code claims per industry-standard guidelines (e.g., UB, AMA CPT, HCPCS, ICD-10, NCCI/CCI).
Be prepared to furnish additional documentation when requested for claim review or adjudication.

Plan Documents and Provider Contracts

Plan documents and provider contracts — Covered Services / plan governance

Governing documentsIf a conflict arises between this policy and any plan document under which a member is entitled to Covered Services, the plan document will govern; if a conflict arises with a provider contract, the provider contract will govern.

Examples of plan documentsPlan documents include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

BCBSNM discretion and authorityBCBSNM may use reasonable discretion in interpreting and applying this policy and has full and final discretionary authority to the extent provided under any applicable plan documents.

Provider responsibility for documentationProviders are responsible for submission of accurate documentation of services performed and are urged to submit any additional documentation upon request.

Claims coding and submission expectationsClaims should be submitted using valid HIPAA-approved code sets and coded per industry standards (e.g., UB, AMA CPT, HCPCS, ICD-10, NDC, DRG, CMS NCCI edits).

Claims subject to reviewClaims are subject to code edit protocols and claim review including benefit terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic.