CurrentCapital BluecrossPolicy MP 2.360

Gene Expression Profiling for Uveal Melanoma

This policy governs coverage for gene expression profiling (DecisionDx-UM) to provide prognostic information for patients with primary, localized uveal melanoma and applies to Capital Blue Cross products as specified.

Policy Summary

PayerCapital Bluecross

PolicyGene Expression Profiling for Uveal Melanoma

Policy CodePolicy MP 2.360

Change TypeAdministrative (minor) and coding updates

Effective Date8/1/2025

Next Review Date

Key ActionPrior authorization may be required and specify procedure code 81552 with relevant ICD-10 codes for uveal melanoma on claims.

SourceLink

POLICY UPDATE CHANGES

Removed gene expression profiling for cutaneous melanoma policy criteria and information; changed policy title to Gene Expression Profiling for Uveal Melanoma.

New code 0490U added; effective 10/01/2024.

Removed codes 0089U, 0090U, 0314U, 0490U, 81529 during 02/18/2025 update.

DecisionDx-UM code 0081U was previously added effective 01/01/2019 (later removed/end-dated).

DecisionDx-UMnamed commercially available GEP test

MP 2.360Policy identifier

Multiple updatesCoding/history activity

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Coverage Criteria

Initial testing (DecisionDx-UM)

Covered when ALL of the following are met

Coverage criteria: Patient has primary, localized uveal melanoma and the test is DecisionDx-UM; testing for other indications is investigational.

Based on policy statement: DecisionDx-UM medically necessary for primary, localized uveal melanoma; tests not meeting criteria are investigational.

Medical necessity — uveal melanoma

Covered when ALL of the following are met for uveal melanoma (as historically stated in policy adoption):

Primary indication: Gene expression profiling for uveal melanoma is considered medically necessary for patients with primary, localized uveal melanoma.

Statement originates from initial policy adoption (MP 2.360, 05/30/2018) as recorded in policy history.

Gene expression profiling tests that do not meet the defined indication of primary, localized uveal melanoma are considered investigational. DecisionDx-UM is medically necessary only when used for patients with primary, localized uveal melanoma; testing performed for other indications falls outside the coverage criteria and may be denied.

Policy history documents that gene expression profiling for cutaneous melanoma had previously been listed as investigational, but related cutaneous melanoma content was removed from this policy in a Minor Review on 02/18/2025. This administrative change narrowed the policy focus to uveal melanoma and updated the policy title accordingly.

Historically, gene expression profiling tests for cutaneous melanoma (examples include Pigmented Lesion Assay/Pigmented Lesion genetic tests) were listed as investigational in the policy history. Those references and associated investigational criteria have been removed from the current policy during administrative updates.

Coding

Procedure CodesCPTCovered

81552

Covered Diagnosis Codes for Uveal MelanomaICD-10Covered

C69.30	Malignant neoplasm of unspecified choroid
C69.31	Malignant neoplasm of right choroid
C69.32	Malignant neoplasm of left choroid
C69.40	Malignant neoplasm of unspecified ciliary body
C69.41	Malignant neoplasm of right ciliary body
C69.42	Malignant neoplasm of left ciliary body
C69.80	Malignant neoplasm of overlapping sites of unspecified eye and adnexa
C69.81	Malignant neoplasm of overlapping sites of right eye and adnexa
C69.82	Malignant neoplasm of overlapping sites of left eye and adnexa
C69.90	Malignant neoplasm of unspecified site of unspecified eye

1–10 of 12

1/2

Covered when medically necessary for UVEAL melanomaCPTCovered

81552

unlisted multianalyte algorithmic assay (MAAA) with algorithmic analysis

Associated ICD-10 diagnosesICD-10

C69.30	Malignant neoplasm of unspecified choroid
C69.31	Malignant neoplasm of right choroid
C69.32	Malignant neoplasm of left choroid
C69.40	Malignant neoplasm of unspecified ciliary body
C69.41	Malignant neoplasm of right ciliary body
C69.42	Malignant neoplasm of left ciliary body
C69.80	Malignant neoplasm of overlapping sites of unspecified eye and adnexa
C69.81	Malignant neoplasm of overlapping sites of right eye and adnexa
C69.82	Malignant neoplasm of overlapping sites of left eye and adnexa
C69.90	Malignant neoplasm of unspecified site of unspecified eye

1–10 of 12

1/2

Other historical or administrative codes referenced in policy historymixed

0081U	DecisionDx-UM (historical code; added 2019, later removed/end-dated)
0089U	Pigmented Lesion Assay (PLA)/DermTech (previously listed investigational for cutaneous melanoma)
0090U	myPath (previously listed investigational for cutaneous melanoma)
0314U	Previously added code (listed in history)
0357U	Previously added 01/01/2023 then removed as deleted code
0490U	New code added 10/01/2024 then later removed
81529	Code added 01/01/2021 then removed
81599	Previously listed code removed
84999	Previously listed code removed
81479	Previously listed code removed

Coding — N/A

Coding entryN/A

Provider Actions & Billing

Denial Risk

Coverage Determination Disclaimer

Coverage is determined by the member's benefit terms and plan contract. Identification of a code in this policy does not guarantee coverage; verify member eligibility and benefits prior to billing.

Coverage determined by member benefit information; code identification is not a guarantee of coverage.

Documentation Required

Coding and Laboratory Documentation

Specify the procedure code 81552 and the relevant ICD-10 diagnosis code(s) for uveal melanoma on the claim. Ensure testing is performed in a CLIA-certified high-complexity laboratory and document the laboratory name, test performed (DecisionDx-UM / 81552), clinical indication (primary, localized uveal melanoma), and supporting pathology or clinical notes in the medical record.

Required CPT/procedure code: 81552
Relevant ICD-10 codes: C69.30, C69.31, C69.32, C69.40, C69.41, C69.42, C69.80, C69.81, C69.82, C69.90, C69.91, C69.92

Background

Uveal melanoma is the most common primary intraocular malignancy in adults and most frequently arises in the choroid. Treatments for localized disease commonly include radiotherapy and surgical approaches, and prognosis is influenced by tumor size and clinical/pathologic risk factors. Genetic and gene expression profiling assays (for example, DecisionDx-UM) have been developed to provide prognostic information by stratifying tumors according to metastatic risk to inform follow-up and management decisions.

Definitions

Gene expression profiling (GEP) — assay description and prognostic stratification

DefinitionGene expression profiling (GEP) is an assay that determines the expression of multiple genes in a tumor to stratify prognostic risk for metastatic disease.

DecisionDx-UM / CLIA status

Test statusDecisionDx-UM is a laboratory‑developed test offered under CLIA (high‑complexity) and has not been subject to FDA regulatory review.

Gene expression profiling summary (DecisionDx-UM)

Assay typeDecisionDx‑UM is a multi‑gene prognostic assay (gene expression profiling) used to classify uveal melanoma tumors by metastatic risk.

Clinical roleProvides prognostic stratification to inform metastatic risk assessment and surveillance planning for patients with primary, localized uveal melanoma.