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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyProvidence Health Plan hCG Coverage Update | OpenP…
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    CurrentProvidence Health PlanPolicy 410

    Human Chorionic Gonadotropin (hCG) testing

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    Defines medical necessity and coverage criteria for quantitative hCG testing for Providence Health Plan commercial members and related plan products; affects ordering providers and billing for laboratory hCG tests.

    Policy Summary
    PayerProvidence Health Plan
    PolicyHuman Chorionic Gonadotropin (hCG) testing
    Policy CodePolicy 410
    Change TypeAnnual review — no material changes
    Effective DateJul 1, 2026
    Last ReviewJul 1, 2026
    Next Review DateMay 1, 2027
    Key ActionOrder quantitative hCG (CPT 84702) only when one of the covered indications is met and include an ICD-10 diagnosis that supports medical necessity per NCD 190.27.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3covered clinical indications
    Commercialplan product applicability
    84702primary quantitative hCG code
    190.27NCD referenced

    Coverage Criteria — Quantitative hCG (CPT 84702)

    Policy Summary
    PayerProvidence Health Plan
    PolicyHuman Chorionic Gonadotropin (hCG) testing
    Policy CodePolicy 410
    Change TypeAnnual review — no material changes
    Effective DateJul 1, 2026
    Last ReviewJul 1, 2026
    Next Review DateMay 1, 2027
    Key ActionOrder quantitative hCG (CPT 84702) only when one of the covered indications is met and include an ICD-10 diagnosis that supports medical necessity per NCD 190.27.
    SourceLink
    On This Page
    Coverage Criteria — Quantitative hCG (CPT 84702)Specific Covered IndicationsCoding — CPT and NotesProvider Actions, Billing, and DocumentationOrdering Requirements and ClaimsDefinitions — CPT Code DescriptionsBackgroundNot Covered / Exclusions

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    inv-01: Covered Indications

    Human Chorionic Gonadotropin (hCG) measurement may be considered medically necessary when ANY of the following are met:

    Medically necessary indications: A. Monitoring and diagnosis of germ cell neoplasms of the ovary, testis, mediastinum, retroperitoneum, and central nervous system; OR B. Monitoring pregnant members with vaginal bleeding, hypertension, and/or suspected fetal loss; OR C. To confirm pregnancy in patients who are undergoing in-vitro fertilization.

    From Providence Health Plan Medical Policy 410

    inv-02: Not Medically Necessary

    Not medically necessary when the above criteria are not met:

    Not medically necessary: hCG measurement is considered not medically necessary when criterion I.-III. above are not met.

    Policy statement declaring NMN for indications outside listed criteria.

    This policy does not address qualitative hCG testing (CPT 84703). Guidance, coverage determination, and coding direction in this document apply to quantitative hCG assays and do not extend to CPT 84703.

    Human chorionic gonadotropin (hCG) measurement is considered not medically necessary when the listed medically necessary indications in Section I (monitoring/diagnosis of germ cell neoplasms; monitoring pregnant members with vaginal bleeding, hypertension, and/or suspected fetal loss; or confirming pregnancy in patients undergoing in‑vitro fertilization) are not met.

    Specific Covered Indications

    inv-15: Monitoring and diagnosis of germ cell neoplasms (ovary, testis, mediastinum, retroperitoneum, CNS)

    Indication: Monitoring and diagnosis of germ cell neoplasms (ovary, testis, mediastinum, retroperitoneum, CNS)

    Covered as listed in policy I.A.

    inv-16: Monitoring pregnant members with vaginal bleeding, hypertension, and/or suspected fetal loss

    Indication: Monitoring pregnant members with vaginal bleeding, hypertension, and/or suspected fetal loss

    Covered as listed in policy I.B.

    inv-17: Confirming pregnancy in patients undergoing in-vitro fertilization

    Indication: To confirm pregnancy in patients who are undergoing in-vitro fertilization

    Covered as listed in policy I.C.

    Coding — CPT and Notes

    Covered CPT Codes (quantitative)CPTCovered
    84702Quantitative hCG
    Qualitative hCG noteCPT
    84703Qualitative hCG (not addressed by this policy)

    Provider Actions, Billing, and Documentation

    Prior Authorization

    Prior authorization guidance

    These quantitative hCG services (CPT 84702) do not require prior authorization routinely; however, unlisted codes for potentially covered services are recommended to be prior authorized to avoid post‑service denial.

    • CPT 84702 is listed as the quantitative hCG code in this policy.
    Documentation Required

    Include ICD‑10 diagnosis and supporting documentation

    Include an appropriate ICD‑10 diagnosis on claims that aligns with Medicare NCD 190.27 and retain documentation that supports meeting the NCD criteria.

    • Order must be accompanied by an ICD‑10 diagnosis that meets NCD 190.27 criteria.
    • Documentation should support meeting NCD criteria to withstand utilization audit.
    Documentation Required

    Required supporting documentation

    Claims should include ICD‑10 diagnosis codes that align with Medicare NCD 190.27 covered diagnoses and documentation should support meeting NCD criteria to withstand utilization audit.

    • Use the Lab NCDs ICD‑10 code list and verify NCD 190.27 in the Covered Code List before billing.
    • Retention of clinical documentation that demonstrates the member meets NCD criteria is required for potential audits.
    Denial Risk

    Audit and coding compliance risk

    Services may be subject to utilization audit and all NCD 190.27 criteria must be met; listing an ICD‑10 code on the Medicare covered list does not guarantee coverage.

    • Inclusion of a diagnosis code on the Medicare covered list may not warrant automatic coverage.
    • Providers should ensure documentation satisfies all NCD 190.27 requirements to avoid denials on audit.
    Denial Risk

    Unlisted code submission risk

    Unlisted procedure codes are reviewed at claim level; unlisted codes submitted for non‑covered services will be denied as not covered, and prior authorization is recommended for unlisted codes submitted for potentially covered services to avoid post‑service denial.

    • All unlisted codes are reviewed for medical necessity, correct coding, and pricing at the claim level.
    • If an unlisted code is for a potentially covered service, obtain prior authorization to reduce risk of denial.

    Ordering Requirements and Claims

    Note

    Ordering requirements — ICD-10 and NCD 190.27

    Order must be accompanied by an ICD-10 diagnosis that meets NCD 190.27 criteria; services may be subject to audit and provider contracts and member benefits apply.

    • Use the Lab NCDs - ICD-10 file and identify NCD 190.27 covered diagnoses to code claims.
    • Inclusion of a diagnosis on the Medicare covered list does not ensure automatic coverage — documentation must meet NCD criteria.

    Definitions — CPT Code Descriptions

    inv-13: CPT 84702 — Quantitative hCG testing
    CPT code84702
    Short descriptionQuantitative hCG testing
    Coverage conditionMay be covered when billed with an ICD-10 diagnosis included as medically necessary in Medicare NCD 190.27 and when policy clinical indications are met
    Prior authorizationNot routinely required; services may be subject to audit
    Test nameQuantitative hCG assay
    inv-14: CPT 84703 — Qualitative hCG testing (not addressed by this policy)
    CPT code84703
    Short descriptionQualitative hCG testing
    Policy statusThis policy does not address CPT 84703; qualitative hCG testing is excluded from coverage guidance in this document
    Action for providersRefer to other applicable policies or payer guidance for qualitative hCG coverage and billing
    Coding noteQuantitative and qualitative hCG are distinct; CPT 84702 is the quantitative code referenced in this policy

    Background

    Human chorionic gonadotropin (hCG) is measured quantitatively to detect and monitor pregnancy and to evaluate certain germ cell neoplasms. Quantitative assays (reported using CPT 84702) are used for diagnosis, monitoring of tumor burden in germ cell neoplasms, and assessment of pregnancy status or viability in clinical scenarios such as in‑vitro fertilization and pregnant patients with concerning symptoms. This policy distinguishes quantitative testing from qualitative testing (CPT 84703), which is not addressed here. Providers should follow the billing and documentation guidance in this policy and the referenced Medicare NCD resources when submitting claims.

    Not Covered / Exclusions

    Qualitative hCG testing (CPT 84703) is not addressed by this policy and is excluded from the coverage guidance provided here. Providers should not rely on this document for coverage determinations or coding instructions for CPT 84703.