CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABO38

Urinary Tumor Markers for Bladder Cancer

Reimbursement criteria for urinary biomarkers and related urinary tumor marker tests for bladder cancer (diagnosis and surveillance), applicable to services billed to Blue Cross Blue Shield of Oklahoma; providers should review specific plan documents for product-level applicability.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyUrinary Tumor Markers for Bladder Cancer

Policy CodePolicy CPCPLABO38

Change TypeClarified — codes addedreferences updated

Effective DateApr 29, 2024

Next Review Date

Key ActionSubmit supporting clinical documentation showing the urinary biomarker test was used as an adjunct for an allowed indication (e.g., monitoring high-risk non-muscle invasive bladder cancer or resolving atypical/equivocal cytology).

SourceLink

POLICY UPDATE CHANGES

Added codes 0420U and 0465U and updated references; reimbursement information remained unchanged.

3Situations where some urinary biomarkers may be reimbursable

2Tests specifically listed as reimbursable in adjunct roles (BTA/NMP22/UroVysion and ImmunoCyt)

15Procedure / CPT/HCPCS codes listed in policy

When Urinary Tumor Marker Tests May Be Reimbursed

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Reimbursable urinary biomarkers - permitted situations

Urinary biomarkers (BTA, NMP22, UroVysion FISH) may be reimbursable when used as an adjunct in any of the following situations:

ANY of the following

As an adjunct in the monitoring of high-risk, non-muscle invasive bladder cancer.
As an adjunct in the diagnostic exclusion of bladder cancer for individuals who have an atypical or equivocal cytology.

Reimbursable fluorescence immunocytology (ImmunoCyt)

Fluorescence immunocytology (ImmunoCyt) may be reimbursable when used as an adjunct to cystoscopy or cytology in monitoring individuals with bladder cancer:

ALL of the following

Used as an adjunct to cystoscopy or cytology in the monitoring of individuals with bladder cancer.

Not reimbursable indications and tests

The following uses and tests are not reimbursable:

ALL of the following

Use for evaluation of hematuria (screening for bladder cancer in asymptomatic individuals or diagnosis in symptomatic individuals) is not reimbursable for urinary biomarkers or fluorescence immunocytology.
Use of urinary biomarkers (BTA, NMP22, UroVysion FISH) for any indications other than those listed as reimbursable is not reimbursable.
Other urinary tumor markers for bladder cancer not specifically mentioned are not reimbursable.

Documentation and Billing Requirements for Providers

Documentation Required

Submit supporting clinical documentation

Providers must submit accurate clinical documentation with claims and may be asked to provide additional records demonstrating the urinary biomarker test was used as an adjunct for an allowed indication (for example, monitoring high‑risk non‑muscle invasive bladder cancer or resolving atypical/equivocal cytology). Upon request, submit supporting documentation to verify the test use meets the policy’s adjunctive indications.

86294
86316
86386
88120
88121
88346
88350
0012M
0013M
0363U
0365U
0366U
0367U
0420U
0465U

Clinical and Administrative Context

This policy defines reimbursement for urinary biomarkers and related urinary tumor marker tests used in the diagnosis and surveillance of bladder cancer, including BTA (bladder tumor antigen), NMP22 (nuclear matrix protein), UroVysion FISH, ImmunoCyt (fluorescence immunocytology), and other urinary tumor markers. The policy applies to services billed to Blue Cross Blue Shield of Oklahoma and may not apply to all products or plan designs; providers should review specific plan documents for product-level applicability.

The tests above are intended to be used as adjuncts to primary diagnostic or surveillance modalities (for example, cystoscopy or cytology) rather than as standalone screening or diagnostic tests. Reimbursement is limited to specific adjunctive uses—for example, adjunctive monitoring of high-risk, non-muscle invasive bladder cancer or adjunctive testing to help resolve atypical or equivocal cytology—and does not cover routine screening or evaluation of hematuria or other indications outside those explicitly listed.

Key Terms

Definitions

AdjunctUse in addition to primary diagnostic or surveillance modalities (for example, cystoscopy or cytology) rather than as a standalone diagnostic or screening test.

High-risk, non-muscle invasive bladder cancerClinical category of non-muscle invasive bladder cancer with features that confer higher risk of recurrence or progression (policy uses this term consistent with common urologic guideline definitions).

Policy Update Timeline

04/29/2024Policy updateLatest

Document updated with a literature review; reimbursement information remained unchanged; codes 0420U and 0465U were added and references were revised.

11/01/2023Policy update

Document updated with a literature review; reimbursement information was revised for clarity and references were revised.

11/01/2022Policy created

New policy established.

Supplemental note: The policy was updated effective 04/29/2024 with a literature review and revised references; codes 0420U and 0465U were added. Reimbursement information in the policy remained unchanged.