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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyProvidence Health Plan AFP Coverage Update | OpenP…
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    CurrentProvidence Health PlanPolicy 407

    Alpha-Fetoprotein (AFP) — Medicare Coverage Criteria (NCD 190.25)

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    Medicare-only policy governing coverage and billing for serum alpha-fetoprotein (AFP) carcinoma testing (CPT 82105) for Providence Health Plan Medicare products and related companies.

    Policy Summary
    PayerProvidence Health Plan
    PolicyAlpha-Fetoprotein (AFP) — Medicare Coverage Criteria
    Policy CodePolicy 407
    Change TypeAnnual review — no material changes
    Effective DateJun 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateMay 1, 2027
    Key ActionBill CPT 82105 with an ICD-10 diagnosis from the CMS Lab NCDs 'Covered Code List' for NCD 190.25 and retain documentation to support medical necessity.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1Covered CPT code
    Medicare OnlyProduct applicability
    NCD 190.25Governing NCD
    AnnualReview cadence

    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.

    Coverage Criteria

    Medicare NCD 190.25 Coverage Criteria

    Covered when billed in accordance with CMS NCD 190.25 and with an ICD-10 diagnosis listed as medically necessary for NCD 190.25.

    NCD-based coverage: Service must be serum AFP (CPT 82105) for carcinoma and billed with an ICD-10 code that Medicare has included as medically necessary in the Lab NCDs - ICD-10 list for NCD 190.25.N/A

    Inclusion on the CMS list does not guarantee coverage; all NCD 190.25 criteria must be met and services remain subject to individualized medical necessity determinations and audit.

    AFP testing of amniotic fluid billed with CPT 82106 is not addressed by this policy or by Medicare NCD 190.25 and is therefore outside the scope of coverage guidance provided here.

    All unlisted procedure codes are reviewed at the claim level. If an unlisted code is submitted for a service that is non‑covered under this policy, the claim will be denied as not covered.

    Covered Indications

    Serum AFP testing for carcinoma indications (per NCD 190.25)

    Covered when billed for carcinoma indications specified by Medicare NCD 190.25 and with an ICD-10 diagnosis included on the CMS Lab NCDs - ICD-10 'Covered Code List' for NCD 190.25.

    Covered indication requirement: Test must be serum alpha-fetoprotein (AFP) — CPT 82105 — performed for carcinoma indications consistent with NCD 190.25.N/A

    Order and claim must include an ICD-10 diagnosis code listed as medically necessary for NCD 190.25 in the Medicare Lab NCDs - ICD-10 covered code list.

    Documentation and billing: Providers should bill CPT 82105 with an ICD-10 diagnosis code that appears on the Medicare Lab NCDs - ICD-10 'Covered Code List' for NCD 190.25 and retain documentation supporting medical necessity; services may be subject to utilization audit.N/A

    While inclusion of a diagnosis on the CMS list is required for coverage, it does not guarantee coverage; all NCD criteria and Medicare guidance must be met.

    Scope limitations: This policy and NCD 190.25 are limited to serum AFP for carcinoma (CPT 82105) and do not address AFP testing of amniotic fluid (CPT 82106).N/A

    CPT 82106 is outside the scope of this NCD and this policy.

    Coding

    Covered CPT Codes (per NCD 190.25)CPTCovered
    82105Alpha-fetoprotein (AFP) (serum) (carcinoma testing) — CPT 82105
    Other AFP CPT Codes (policy note)CPT
    82106Alpha-fetoprotein (AFP) (amniotic fluid) — CPT 82106 (not addressed by this policy/NCD)

    Provider Actions & Billing Guidance

    Prior Authorization

    Prior authorization: CPT 82105 generally not required; unlisted codes recommend PA

    AFP testing billed with CPT 82105 does not require routine prior authorization; however, utilization may be subject to audit and all NCD 190.25 criteria must be met. For unlisted codes submitted for potentially covered services, prior authorization is recommended to avoid post-service denial.

    • CPT 82105 ordinarily does not require prior authorization.
    • Utilization may be audited and all NCD 190.25 criteria must be met.
    • Unlisted codes for potentially covered services: prior authorization recommended.
    Documentation Required

    Retention of documentation and follow Medicare ordering requirements

    Order and claim submissions should include documentation and diagnosis linkage per Medicare NCD guidance; retain records to support medical necessity in the event of audit.

    • Follow Medicare and member Evidence of Coverage requirements.
    • Retain documentation supporting medical necessity for potential audits.
    Billing Rule

    Billing: use an ICD-10 from the Lab NCDs 'Covered Code List' with CPT 82105

    Bill CPT 82105 with an ICD-10 diagnosis code that appears on the Medicare Lab NCDs - ICD-10 'Covered Code List' for NCD 190.25 and follow the applicable NCD for billing and repeat testing instructions.

    • Locate the 'Lab Code List ICD10' file and find NCD 190.25 in column A to identify covered ICD-10 codes.
    • Follow the applicable NCD for test coverage, utilization limits, and repeat testing billing instructions.
    Denial Risk

    Diagnosis linkage required — risk of denial without NCD-listed ICD-10

    Claims for AFP testing (CPT 82105) may be denied if billed without an ICD-10 diagnosis code that Medicare has listed as medically necessary in the Lab NCDs - ICD-10 covered code list for NCD 190.25.

    • Inclusion of a diagnosis on the CMS list does not guarantee coverage; all NCD 190.25 criteria must be met.
    • Claims lacking an appropriate NCD-listed diagnosis risk denial.
    Denial Risk

    Unlisted code submissions may be denied if they represent non-covered services

    Unlisted codes submitted for services addressed in this policy will be denied as not covered when they correspond to non-covered services; unlisted codes for potentially covered services are reviewed and prior authorization is recommended to avoid post-service denial.

    • All unlisted codes are reviewed for medical necessity and correct coding at the claim level.
    • If an unlisted code represents a non-covered service addressed in this policy, it will be denied as not covered.

    Ordering Requirements

    Documentation Required

    Ordering requirement — include CMS-listed ICD-10 diagnosis

    Orders for serum AFP testing (CPT 82105) must include an appropriate ICD-10 diagnosis from the CMS Lab NCDs - ICD-10 'Covered Code List' for NCD 190.25; providers should follow Medicare/member EOC requirements and retain documentation for potential audits.

    • Identify appropriate ICD-10 codes by downloading the Lab NCDs - ICD10 ‘Covered Code List’ and locating NCD 190.25.
    • Keep documentation of medical necessity available for audit.

    Frequency Limits

    inv-15: Serum AFP (CPT 82105) — Frequency & audit
    Test and CPT codeSerum alpha-fetoprotein (AFP) for carcinoma — CPT 82105
    Utilization auditAFP testing (CPT 82105) does not require routine prior authorization but may be subject to utilization audit per NCD 190.25
    Repeat testing/billingRepeat testing and billing instructions follow the applicable NCD; see NCD 190.25 for limits and guidance

    Definitions

    inv-12: Serum AFP (CPT 82105) — Definition & billing
    DefinitionAFP testing for carcinoma refers to serum alpha-fetoprotein measurement billed with CPT 82105.
    Governing NCDCoverage governed by Medicare NCD 190.25 — service limited to carcinoma use for CPT 82105.
    Billing requirementMust be billed with an ICD-10 diagnosis listed as medically necessary in the CMS Lab NCDs - ICD10 'Covered Code List' for NCD 190.25.
    inv-13: Amniotic AFP (CPT 82106) — Exclusion
    DefinitionAFP testing of amniotic fluid is billed under CPT 82106 and is not addressed by this policy or NCD 190.25.
    ScopeCPT 82106 (amniotic AFP) falls outside the scope of this policy and the referenced NCD; coverage guidance here does not apply.
    Coding noteDo not substitute CPT 82105 guidance for CPT 82106; treat amniotic fluid AFP as a separate test for coding and coverage considerations.

    Not Covered

    AFP testing of amniotic fluid (CPT 82106) is not addressed by this policy or NCD 190.25 and therefore is not covered under the Medicare coverage criteria outlined here.

    Background

    Alpha‑fetoprotein (AFP) is a serum tumor marker addressed by Medicare NCD 190.25 for carcinoma testing when billed as CPT 82105. This policy applies to AFP testing for carcinoma under the referenced NCD and to Providence Health Plan Medicare products; it does not apply to AFP testing of amniotic fluid (CPT 82106).

    Policy Summary
    PayerProvidence Health Plan
    PolicyAlpha-Fetoprotein (AFP) — Medicare Coverage Criteria
    Policy CodePolicy 407
    Change TypeAnnual review — no material changes
    Effective DateJun 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateMay 1, 2027
    Key ActionBill CPT 82105 with an ICD-10 diagnosis from the CMS Lab NCDs 'Covered Code List' for NCD 190.25 and retain documentation to support medical necessity.
    SourceLink
    On This Page
    Coverage CriteriaCovered IndicationsCodingProvider Actions & Billing GuidanceOrdering RequirementsFrequency LimitsDefinitionsNot CoveredBackground