CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB030

In Vitro Chemoresistance and Chemosensitivity Assays

Defines BCBSOK reimbursement stance for in vitro chemosensitivity and chemoresistance laboratory assays and guides providers on claim submission and coding expectations; applies to providers and covered members under BCBSOK plans.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyIn Vitro Chemoresistance and Chemosensitivity Assays

Policy CodePolicy CPCPLAB030

Change TypeRevised reimbursement wordingreferences updated

Effective DateFeb 1, 2024

Next Review DateN/A

Key ActionSubmit accurate documentation and provide additional records upon request to support claims.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Information revised for clarity.

Document updated with literature review and references revised.

2assay categories explicitly stated as not reimbursable

1.0policy version

Feb 1, 2024effective date

multiplesupporting citations provided

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Reimbursement criteria

BCBSOK reimbursement stance for in vitro assays:

ALL of the following

NOT REIMBURSABLE
- In vitro chemosensitivity assays are not reimbursable (examples: histoculture drug response assay, fluorescent cytoprint assay).
- In vitro chemoresistance assays are not reimbursable (example: extreme drug resistance [EDR] assays).

ALL of the following

BCBSOK has implemented certain lab management reimbursement criteria. Not all requirements apply to each product; providers are urged to review Plan documents for eligible coverage for services rendered.

Provider Documentation, Claims, and Review Procedures

Documentation Required

Provider documentation and claim submission

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid HIPAA-approved code sets. Upon request, providers are urged to submit any additional documentation to support the claim.

Submit claims using valid HIPAA-approved code sets and appropriate industry-standard coding guidelines (e.g., UB, AMA CPT, HCPCS, ICD-10-CM/PCS).
Provide additional documentation when requested to support medical necessity and coding.

Denial Risk

Claims subject to review

Claims are subject to code edit protocols and review; adjudication will consider benefit terms, provider contract language, medical policies, CPCPs and coding software logic.

Claims may be edited per code edit protocols (e.g., CCI table edits, NCCI guidance).
Claim review includes plan documents, provider contracts, medical policies, clinical payment and coding policies, and coding software logic — these sources will govern coverage determinations.

Policy Hierarchy and Assay Examples

Policy hierarchy / governing documents

Governing precedenceIf a conflict exists between a Clinical Payment and Coding Policy (CPCP) and a plan document, the plan document will govern; if a conflict exists between a CPCP and 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.

BCBSOK discretionBCBSOK may use reasonable discretion in interpreting and applying this policy to services in a particular case and has full and final discretionary authority to the extent provided under applicable plan documents.

Provider responsibilityProviders are responsible for submission of accurate documentation of services performed and should code claims using valid HIPAA‑approved code sets and industry standard coding guidelines.

Assay examples

In vitro chemosensitivity assay examplesHistoculture drug response assay; fluorescent cytoprint assay.

In vitro chemoresistance assay exampleExtreme drug resistance (EDR) assays.

Assay category stanceBoth in vitro chemosensitivity and chemoresistance assays are not reimbursable under this policy.