ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB038

Urinary Tumor Markers for Bladder Cancer

This policy defines Blue Cross Blue Shield of New Mexico's reimbursement stance for urinary tumor marker tests used in the diagnosis and surveillance of bladder cancer and explains when those tests may or may not be reimbursable for members and providers.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyUrinary Tumor Markers for Bladder Cancer

Policy CodePolicy CPCPLAB038

Change TypeCodes addedliterature/references updated

Effective DateApr 29, 2024

Next Review Date

Key ActionProviders must submit accurate documentation and provide additional documentation upon request for claim review.

SourceLink

POLICY UPDATE CHANGES

Added codes 0420U and 0465U.

Document updated with literature review; references revised.

14procedure and proprietary codes listed in the policy

2new unique codes added

2use-cases potentially reimbursable

4not reimbursable situations listed

1.0

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Coverage Criteria for Urinary Tumor Marker Tests

Coverage criteria for urinary tumor markers

Covered when ALL of the following criteria and operational notes are met:

Reimbursement applies only as specified below; providers should review plan documents for product-specific applicability and submit documentation upon request.

ONE of

Urinary biomarkers (bladder tumor antigen/BTA test, nuclear matrix protein/NMP22 test, or fluorescence in situ hybridization/FISH UroVysion Bladder Cancer test) used as an adjunct in the diagnostic exclusion of bladder cancer for individuals with atypical or equivocal cytology.
Urinary biomarkers (BTA, NMP22, UroVysion FISH) used as an adjunct in the monitoring of high-risk, non-muscle invasive bladder cancer (NMIBC).

Fluorescence immunocytology (ImmunoCyt/uCyt) used as an adjunct to cystoscopy or cytology in the monitoring of individuals with bladder cancer.

Claims are subject to code edit protocols and review against benefit coverage terms, provider contract language, medical policies, and coding software logic; providers may be asked to provide additional documentation to support medical necessity.

The inclusion of procedure or proprietary codes in the policy (e.g., listed laboratory and proprietary codes) does not guarantee coverage or payment; code appropriately and verify plan-specific coverage.

Coverage summary note

Summary of recent policy update and coding changes:

The policy was updated with a literature review and references were revised; reimbursement information in the update log is stated as unchanged.

Procedure/proprietary codes were appended to the policy; specifically, codes 0420U and 0465U were added as noted in the policy update history.

Although codes were added, the policy notes that reimbursement information remained unchanged in the 04/29/2024 update.

Procedure and Proprietary Codes

Listed procedure and proprietary codesmixed

86294
86316
86386
88120
88121
88346
88350
0012M
0013M
0363U

1–10 of 15

1/2

Listed procedure and proprietary codes (duplicate group note)mixed

No codes listed

Added codesCPT

0420U	Newly added test code (policy lists addition)
0465U	Newly added test code (policy lists addition)

Provider Documentation, Billing, and Claims Review

Documentation Required

Documentation and claims review

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid HIPAA-approved code sets. Claims are subject to code edit protocols and review against benefit terms, provider contract language, medical policies, and coding software logic; upon request, providers are urged to submit any additional documentation.

Submit claims using valid HIPAA-approved code sets (e.g., CPT, HCPCS, ICD-10).
Claims may be reviewed against plan documents, provider contracts, and coding policies.
Provide additional documentation when requested to support coverage and reimbursement.

Billing Rule

Billing/code update note

Definitions and Reference Context

Reimbursement criteria

DefinitionLab management reimbursement criteria: BCBSNM-implemented criteria that govern reimbursement for laboratory services; not all requirements apply to each product and providers should review plan documents for coverage applicability.

Provider responsibilityProviders must submit accurate documentation and use valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, etc.); claims are subject to code edit protocols and review and providers may be asked to provide additional documentation.

Coverage applicationListed urinary tumor marker tests may be reimbursable only in limited circumstances (e.g., adjunct to atypical/equivocal cytology or monitoring high‑risk NMIBC); inclusion of procedure codes in the policy does not guarantee coverage.

Claims review basisClaims are reviewed against benefit coverage terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic.

Plan governanceIf a conflict exists between this Clinical Payment and Coding Policy and a member's plan document or provider contract, the plan document or contract governs as applicable.