Supply supporting documentation for listed and unlisted procedure codes

Procedure codes listed in Medical Policy documents are provided as a general reference and may not be all‑inclusive; when submitting claims for proprietary assays or unlisted procedures (for example, CPT 84999) provide supporting clinical documentation and test description to justify medical necessity.

• Confirm the exact procedure code(s) with billing staff or the performing laboratory before submission.
• When using an unlisted chemistry code (84999) include the test name, methodology, and relevant clinical rationale in the claim or prior authorization packet.

Verify benefits and prior authorization before ordering

Coverage is determined by the listed indications in the policy; providers must verify the member's benefit coverage and any payer authorization requirements prior to ordering the test.

• Application of coverage criteria depends on the individual's benefit coverage at the time of request.

Potential prior authorization for proprietary and unlisted tests

Certain proprietary oncology U‑codes and unlisted chemistry procedures identified in the policy may require payer prior authorization; verify authorization requirements for codes such as 0404U, 0558U, 0559U, and unlisted chemistry 84999 before ordering.

• Examples of proprietary codes in the policy: 0404U, 0558U, 0559U.
• Unlisted chemistry code: 84999 — confirm prior auth rules for unlisted procedures.

Code updates may affect prior authorization and billing

The CPT code set in this policy was updated — CPT codes 0558U and 0559U were added (effective 7/1/2025) and CPT 83615 was removed; any prior authorization requirements apply to the codes active on the date of service, so confirm coverage and authorization for the current code in force.

• Added codes effective 7/1/2025: 0558U, 0559U.
• Removed code: 83615 — ensure claims use appropriate current codes.

Summary of provider operational actions

Providers should follow the operational notes in this policy: verify benefits, confirm coding/authorization, and document the specific clinical indication on the order to support medical necessity.

• Verify member benefit coverage and applicable government policies (e.g., LCD/NCD).
• Confirm appropriate CPT/HCPCS or unlisted code and prior authorization requirements before testing.
• Include the clinical indication on the order consistent with the policy table.

Verify benefit-specific and government policy alignment (LCD/NCD)

Application of the policy depends on the individual's benefit coverage and any applicable government policies; if there is a conflict with Medicare/Medicaid (LCD/NCD), the government policy prevails.

• Check Applicable State and Federal Regulations section for Medicare/Medicaid specifications.
• Use government policy to determine coverage when conflicts exist.

Document the specific clinical indication matching the updated biomarker table

When ordering, document the clinical indication that corresponds to the entries in the updated Serum Biomarkers table (for example: initial evaluation/workup, monitoring/follow‑up, or occult primary) to support medical necessity.

• Examples of acceptable indications: initial workup, monitoring/follow‑up, occult primary, workup for specified cancers.

Out‑of‑scope indications risk denial

Ordering or performing serum biomarker testing for cancer indications not discussed in this policy or for biomarkers/tests not addressed does not meet coverage criteria and may be denied.

• Policy expressly states that biomarkers used for indications not discussed do not meet coverage criteria.

Risk of denial for unsupported or unlisted procedure codes

Claims may be denied if procedure codes submitted are not supported by the policy's listed codes or if unlisted chemistry codes (e.g., 84999) are used without appropriate supporting documentation.

• Ensure chosen CPT/HCPCS code matches the policy-listed procedure for the test performed.
• Provide documentation when using unlisted procedure codes to avoid denial.

Coverage limited to updated biomarker indications (LDH removed)

Coverage is limited to the biomarker indications listed in the updated table; tests using biomarkers removed from the table (for example, LDH) or for indications not listed are not covered.

• Lactate dehydrogenase (LDH) was removed from the serum biomarker table and is excluded from coverage as a serum tumor biomarker.
• Perform testing only for indications explicitly listed in the policy table to support coverage.

Verify benefit coverage and follow laboratory/payer guidance before ordering

Before ordering any serum biomarker test, verify the member's benefit coverage and any applicable government policies (LCD/NCD); ordering should also follow laboratory and payer guidance.

• Benefit verification should occur at the time of the request.
• Follow laboratory instructions and payer-specific ordering requirements.

No specific ordering‑provider restrictions stated

This policy excerpt does not specify restrictions on who may order the tests; there are no specific ordering provider restrictions noted in the provided policy text.

• If local payer rules impose ordering provider restrictions, follow those rules.

Include specific clinical indication on the order

Orders must include documentation of the specific clinical indication consistent with the updated Serum Biomarkers table (for example: initial workup, monitoring/follow‑up, occult primary) to substantiate medical necessity.

• Include the clinical reason on the requisition or supporting records submitted with the claim.

Include supporting documentation when using unlisted or proprietary codes

When submitting claims with unlisted procedure codes (such as 84999) or proprietary assay codes, include supporting clinical documentation describing the test and rationale to substantiate the claim.

• Documentation should describe the assay, the analyte measured, and the clinical indication.

Verify benefits and applicable government policies before ordering

Providers must verify benefit coverage and applicable government policies (e.g., LCD/NCD) before ordering; order according to the listed indications in the policy and laboratory guidance.

• Coverage determinations depend on the member's benefit at time of request.
• Government policies supersede this policy if conflicts exist.

No ordering‑provider restrictions specified in excerpt

No specific restrictions on who may place orders are specified in the provided policy excerpt.

• Follow any payer- or facility-specific ordering restrictions if present elsewhere.

Order must document the specific clinical indication consistent with policy table

Ensure each order includes documentation of the precise clinical indication that aligns with the updated Serum Biomarkers table (for example: initial evaluation/workup, monitoring/follow‑up, or occult primary) to support medical necessity and claims adjudication.

• Common acceptable indications include initial workup, monitoring for response, surveillance, and occult primary evaluation as listed in the table.