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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyBlue KC 5‑Fluorouracil TDM Coverage | OpenPayer
    Ask Trek AI about this page
    CurrentBlue KCPolicy POL-PP-315

    Therapeutic Drug Monitoring for 5‑Fluorouracil

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    This payment policy governs reimbursement decisions for therapeutic drug monitoring used to manage dose adjustment of 5‑fluorouracil and specifies tests that do not meet coverage criteria; it applies to providers and facilities submitting claims to Blue KC across commercial and Medicare Advantage lines of business.

    Policy Summary
    PayerBlue KC
    PolicyTherapeutic Drug Monitoring for 5‑Fluorouracil
    Policy CodePolicy POL-PP-315
    Change TypeRoutine review — no material changes
    Effective DateJul 1, 2025
    Next Review DateJul 1, 2026
    Key ActionConfirm member benefits and eligibility at time of request because coverage is contingent on individual benefits.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Commercial + MA + ACA QHP + Small Group + FEPlines of business impacted
    2 testsnon‑covered test types

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    S3722, 80299, 82542, 83789
    codes mentioned
    07/01/2025 → 07/01/2026policy schedule

    Reimbursement and Exclusion Criteria

    Reimbursement criteria and exclusions

    Coverage is conditional based on member benefits and clinical context.

    Coverage determination depends on the member's benefit coverage at the time of the request.
    TDM to aid in managing dose adjustment for individuals undergoing 5‑fluorouracil chemotherapy may be reimbursed.

    Non‑reimbursed tests

    • Uracil breath tests are not reimbursed due to lack of supporting published scientific literature.
    • Dihydrouracil/uracil ratio testing of plasma, serum, or urine samples is not reimbursed due to lack of supporting published scientific literature.
    Exclusion rationale

    These exclusions apply because available published scientific literature does not confirm the tests are required and beneficial for diagnosis or treatment.

    Procedure Codes and Non‑Reimbursed Tests

    Example procedure codes referencedmixed
    S3722Dose optimization by area under the curve (AUC) analysis, for infusional 5‑fluorouracil
    80299Quantitation of therapeutic drug, not elsewhere specified
    82542Column chromatography, includes mass spectrometry, if performed (eg, HPLC, LC, LC/MS, LC/MS-MS, GC, GC/MS-MS, GC/MS, HPLC/MS), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen
    83789Mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen
    Non‑reimbursed tests (examples)
    Uracil breath testsSpecifically listed as not meeting coverage criteria and may not be reimbursed due to lack of supporting published literature.
    Dihydrouracil/uracil ratio testingDihydrouracil/uracil ratio testing of plasma, serum, or urine samples is listed as not meeting coverage criteria and may not be reimbursed.

    Provider Guidance and Coverage Determination Notes

    Prior Authorization

    Coverage depends on individual benefits and clinical context

    Application of coverage criteria depends on the member's specific benefit coverage and the clinical context; TDM to aid dose adjustment for individuals undergoing 5‑fluorouracil chemotherapy may be reimbursed when consistent with the member's benefits and clinical situation.

    Denial Risk

    Non‑reimbursed tests — do not submit for reimbursement

    The policy lists specific tests that do not meet coverage criteria and may not be reimbursed because there is a lack of published scientific literature demonstrating they are required and beneficial.

    • Uracil breath tests
    • Dihydrouracil/uracil ratio testing of plasma, serum, or urine

    Definitions and Related Policies

    Therapeutic drug monitoring (TDM) — definition and context
    Definition of TDMTherapeutic drug monitoring (TDM) — measurement of drug concentrations to aid in dose adjustment for infusional 5‑fluorouracil; used to help manage dose adjustment for individuals undergoing 5‑fluorouracil chemotherapy.
    Clinical rationaleChemotherapeutic agents like 5‑fluorouracil have a narrow therapeutic index; TDM is proposed to identify optimal dosing to improve patient management.
    Coverage contextApplication of coverage criteria for TDM is dependent on an individual’s benefit coverage at the time of the request; TDM to aid dose adjustment may be reimbursed for those undergoing 5‑fluorouracil chemotherapy.
    Pharmacogenetic testing (out of scope)
    Policy scope — pharmacogeneticsThis policy does not address pharmacogenetic testing to aid or direct chemotherapies.
    Policy Summary
    PayerBlue KC
    PolicyTherapeutic Drug Monitoring for 5‑Fluorouracil
    Policy CodePolicy POL-PP-315
    Change TypeRoutine review — no material changes
    Effective DateJul 1, 2025
    Next Review DateJul 1, 2026
    Key ActionConfirm member benefits and eligibility at time of request because coverage is contingent on individual benefits.
    SourceLink
    On This Page
    Reimbursement and Exclusion CriteriaProcedure Codes and Non‑Reimbursed TestsProvider Guidance and Coverage Determination NotesDefinitions and Related Policies
    Cross‑reference
    Refer to AHS-M2021 for guidance on pharmacogenetic testing.
    Implication for claimsPharmacogenetic testing considerations and coverage determinations are handled under the referenced AHS-M2021 policy, not within this TDM policy.