Alpha-Fetoprotein (AFP) testing
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Defines medical necessity and coverage criteria for serum alpha-fetoprotein (AFP) testing for Providence Health Plan members, applicable primarily to commercial products and per plan benefit terms.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically necessary indications
Covered when ANY of the following are present:
Link to Evidence Summary
Alpha‑fetoprotein (AFP) testing is covered only when the criteria listed in Section I (A–C) are met. AFP testing is considered not medically necessary when the criteria in Section I are not met.
Any AFP testing performed for indications other than those explicitly listed in Section I (A–C) is not medically necessary and not covered under this policy.
Covered Indications
Diagnosis of hepatocellular carcinoma in high-risk patients
Differentiation of hepatocellular carcinoma from benign hepatocellular neoplasms or metastases
Marker for germ cell neoplasms of testis, ovary, retroperitoneum, and mediastinum
Coding
| 82105 | Alpha-fetoprotein (AFP); serum |
| No codes listed |
Provider Actions & Billing Notes
Recommend prior authorization for unlisted codes
Prior authorization is recommended to avoid post-service denial when an unlisted code is submitted for potentially covered services (CPT 82105).
- Applies when an unlisted code is used for a service that may be covered under this policy.
Step therapy
No step therapy requirements are specified in this policy.
Link CPT 82105 to NCD-listed ICD-10 diagnosis codes
AFP (CPT 82105) may be considered for coverage when billed with an ICD-10 diagnosis included in the most recent Medicare NCD Coding Policy Manual; see that coding manual for the complete list of diagnosis codes.
- Providers should bill CPT 82105 with an ICD-10 code listed in the Medicare NCD Coding Policy Manual to be considered for coverage.
Denial risk for unlisted codes on non-covered services
All unlisted codes submitted for non-covered services addressed in this policy will be denied as not covered.
- Unlisted codes are reviewed for medical necessity, correct coding, and pricing at the claim level; denial will occur if the service is non-covered.
Ordering Requirements
Bill with NCD-listed ICD-10 diagnosis
Must be billed with an ICD-10 diagnosis included in the most recent Medicare NCD Coding Policy Manual to be considered for coverage; see the coding policy manual for a complete list of diagnosis codes.
Frequency Limits
Not Covered
Background
Alpha‑fetoprotein (AFP) is a biochemical marker used to monitor response to therapy in certain malignancies. It functions as a tumor marker particularly in hepatocellular carcinoma and in some germ cell tumors, and can assist in distinguishing hepatocellular carcinoma from other hepatic neoplasms or metastases.
Definitions
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