Benefit verification required

Verify the member's benefit coverage and any applicable Medicare/Medicaid rules at the time of the request; coverage determination depends on the individual's benefits and government policies referenced in the Applicable State and Federal Regulations section.

Procedure and proprietary test codes (reference only)

Procedure and proprietary test CPT/HCPCS codes listed in the policy are provided for reference; the policy lists multiple codes (see coding tables) but does not state explicit prior authorization requirements in this section.

• Examples: 83521, 83789, 83880, 86301, 86304, 86305, 0003U (Overa™), 0092U (REVEAL).

Code updates — check prior authorization

CPT codes 0558U and 0559U were added effective 7/1/2025 and CPT code 83615 was removed; providers should check whether prior authorization or other coverage requirements apply to these newly added or removed codes.

• New: 0558U, 0559U (effective 7/1/2025).
• Removed: 83615.

Order tests per policy indications and frequency

Follow policy-specified indications and frequency guidance when ordering tests; ensure orders are consistent with the marker-specific coverage entries in the policy table.

Align testing and documentation to updated biomarker table

When ordering or reporting biomarkers, reference the updated biomarker table for allowed indications (workup, initial evaluation, monitoring/follow-up, occult primary) and align documentation to those table entries.

Operational note — coding and order documentation

Ensure laboratory tests are performed and reported in accordance with the policy's laboratory and coding guidance and that orders reflect clinical context supporting covered indications.

• Use codes listed in the policy as a reference; they may not be exhaustive.
• Include clinical indication on the order to match table-concordant use.

Regulatory precedence — government policy supersedes

If there is a conflict between this policy and any applicable government policy (e.g., LCD/NCD or state Medicaid), the government policy supersedes; providers should consult the Medicare Coverage Database or applicable state Medicaid site for current rules.

• Medicare policies: https://www.cms.gov/medicarecoverage-database/search.aspx
• Check applicable state Medicaid websites for state-specific rules.

Document specific clinical indication on orders

Include the specific clinical indication on the order that matches an entry in the updated serum biomarker table (e.g., occult primary, initial workup, monitoring/follow-up, Castleman disease for serum free light chains).

• Document whether the test is for workup, initial evaluation, monitoring/follow-up, surveillance, or specific disease workup.

Noncovered uses — risk of denial

Ordering biomarkers for cancer indications not discussed in the policy, or using serum tumor markers not addressed in the policy, does not meet coverage criteria and may result in a denial.

• Analysis of proteomic patterns in serum for cancer screening/detection also does not meet coverage criteria.

Codes listed for reference only — verify coverage

Procedure and proprietary test codes shown in the policy are provided as a general reference and do not imply coverage; they may not be all‑inclusive and do not replace benefit verification.

• Codes listed include CPT/HCPCS and proprietary algorithm codes; verify coverage for each code with benefits prior to ordering.

Coverage is tied to table indications — out-of-table testing risks denial

Testing performed for indications outside the updated biomarker table (for example, LDH testing which was removed) may be considered not medically necessary and subject to denial.

• LDH section was removed from the biomarker table and is excluded from this designation.

Verify benefits and applicable government policies before ordering

Coverage determination must align with the member's benefit coverage and any applicable government (Medicare/Medicaid) policies; providers should verify benefits and applicable government rules prior to ordering.

Include clinical-indication documentation on orders

Include documentation of the clinical indication on the order consistent with the biomarker table entries (e.g., workup, initial evaluation, monitoring/follow-up) to support medical necessity.