Molecular Pathology/Molecular Diagnostics/Genetic Testing · 2020-01-04 · Molecular Pathology/Molecular Diagnostics/Genetic Testing Page 2 of 55 UnitedHealthcare Medicare Advantage

Molecular Pathology/Molecular Diagnostics/Genetic Testing Page 1 of 33 UnitedHealthcare Medicare Advantage Policy Guideline Approved 01/08/2020

Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc.

MOLECULAR PATHOLOGY/MOLECULAR DIAGNOSTICS/ GENETIC TESTING

Guideline Number: MPG210.13 Approval Date: January 8, 2020 Table of Contents Page POLICY SUMMARY......................................................1 APPLICABLE CODES ...................................................4 PURPOSE ..................................................................5 REFERENCES.............................................................5 GUIDELINE HISTORY/REVISION INFORMATION .......... 31 TERMS AND CONDITIONS......................................... 32 POLICY SUMMARY Overview This policy overview addresses molecular and genetic tests that have proven efficacy according to CMS, in the diagnosis or treatment of medical conditions, including but not limited to the following: Hereditary Breast and Ovarian Cancer Anomalies in two genes, BRCA1 and BRCA2, are associated with an increased risk of breast and ovarian cancer. Alterations in BRCA1 and BRCA2 explain many, but not all, of inherited forms of breast and ovarian cancer. With the identification of BRCA1 and BRCA2, it is now possible to test for abnormalities in the genes to provide information on the future risk of cancer and to make important treatment decisions in affected individuals. Approximately five to ten percent of all breast cancers, and a similarly small percentage of ovarian cancers, are attributed to dominantly inherited susceptibility. (Refer to the LCDs for Cancer section for specific coverage guidelines.) Gene Expression Assays for Breast Cancer Treatment, including but not limited to: • Breast Cancer Index (BCI)® Genetic Assay • EndoPredict® • MammaPrint® • Oncotype DX™ • Oncotype DX DCIS • Prosigna™ Breast Cancer Prognostic Gene Signature Assay (Refer to the LCDs for Cancer section for specific coverage guidelines.) Hereditary Colorectal and Endometrial Cancer Syndromes Lynch Syndrome (previously denoted as Hereditary Non - Polyposis Colorectal Cancer (HNPCC) syndrome), is an autosomal dominant syndrome that accounts for about 3 - 5% of colorectal cancer cases. HNPCC syndrome mutations occur in the following genes: hMLH1, hMSH2, hMSH6, PMS2 and EPCAM. Colorectal cancers associated with Lynch syndrome occur at a younger age (average age of onset between 44 - 61 years of age) compared with the more common colorectal cancers typically found during the seventh decade of life. Gynecologic cancers may precede

Related Medicare Advantage Policy Guidelines • Biomarkers in Cardiovascular Risk Assessment • Clinical Diagnostic Laboratory Services • Molecular Diagnostic Infectious Disease Testing • Molecular Pathology Procedures for Human

Leukocyte Antigen (HLA) Typing • Tier 2 Molecular Pathology Procedures

Related Medicare Advantage Reimbursement Policies • Laboratory Services Policy, Professional • Clinical Laboratory Improvement Amendments

(CLIA) ID Requirement Policy, Professional

Related Medicare Advantage Coverage Summaries • Genetic Testing • Laboratory Tests and Services

UnitedHealthcare® Medicare Advantage Policy Guideline

Terms and Conditions

See Purpose

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/b/biomarkers-cardiovascular-risk-assessment.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/c/clinical-diagnostic-laboratory-services.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/m/molecular-diagnostic-infectious-disease-testing.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/m/molecular-pathology-procedures-hla-typing.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/m/molecular-pathology-procedures-hla-typing.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/t/tier-2-molecular-pathology-procedures.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-reimbursement/MEDADV-Laboratory-Services-Policy.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-reimbursement/MEDADV-CLIA-ID-Requirement-Policy.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-reimbursement/MEDADV-CLIA-ID-Requirement-Policy.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/genetic-testing.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/laboratory-tests-services.pdf



colorectal cancer in as many as 50% of female HNPCC gene mutation carriers. (See LCDs for Cancer section for specific coverage guidelines.) Gene Identification, including but not limited to the following genes: • APC • BCR/ABL1 • BRAF • CYP2C19

• CYP2D6 • EGFR • JAK2 • KRAS

• MGMT • MUTYH • NRAS

(Refer to the LCDs and Articles section for specific coverage guidelines.) Multiple Myeloma Gene Expression Profile MyPRS™ is a test for Multiple Myeloma Gene Expression Profile. Multiple myeloma is an incurable malignancy of terminally differentiated antibody secreting plasma cells. The median overall survival is reported at 3 - 4 years. Disease sequelae associated with this malignancy includes anemia, immunodeficiency, renal insufficiency/failure, lytic bone lesions and hypercalcemia. This test is used only after an initial diagnosis of multiple myeloma has been made and will be available to be used in stratification of therapeutic interventions. The coverage is set to include only two clinical settings: • Once after initial diagnosis is made, or • If relapse has occurred and a change in the therapeutic modalities is contemplated

(See LCDs in Cancer section for coverage guidelines.) Acute Lymphoblastic Leukemia (ALL) or Multiple Myeloma (MM) Sequencing Minimal Residual Disease (MRD) refers to a measure of cancer cells that remain in a person during and following treatment. Testing for MRD using the clonoSEQ® assay is reasonable and necessary when performed on bone marrow specimens in patients with B - Cell acute lymphoblastic leukemia (ALL) or multiple myeloma. (See LCDs in Cancer section for coverage guidelines.) Loss of Heterozygosity Based Topographic Genotyping with PathfinderTG ® /PancraGEN™Test for Pancreatic Cyst/Mass Combining pathologic study with molecular analyses of microdissected tissue, is claimed to enhance the ability to provide more specific diagnostic information, to help guide treatment decisions. These testing combinations are generally known as topographic genotyping. (See LCD Miscellaneous section for coverage guidelines.) Circulating Tumor Cell (CTC) Assay CTCs represent the point in the metastatic process of solid tumors when cells from a primary tumor invade, detach, disseminate, colonize and proliferate in a distant site. Detection of elevated CTCs during therapy may be an accurate indication of subsequent rapid disease progression and mortality in breast, colorectal and prostate cancer, noting that FDA labeling includes each of these neoplasms. As a result of limited acceptable study data, CTCs are considered not medically necessary, for all indications. (See LCDs for CTCs for specific coverage guidelines.) Bladder Tumor Markers, including but not limited to: Bladder Tumor Marker tests include: BTA TRAK®, Nuclear matrix protein 22 (NMP - 22), NMP - 22 BladderChek®, The UroVysion®, BTA (bladder tumor antigen) stat®, and The ImmunoCyt™. (See LCDs for Cancer section for coverage guidelines.) NSCLC (Non - Small Cell Lung Cancer) Testing Guardant360® (Guardant Health, Redwood City, CA), is a plasma - based comprehensive somatic genomic profiling test (hereafter called CGP) for patients with Stage IIIB/IV non - small cell lung cancer (NSCLC). Plasma - based CGP can help patients avoid an invasive biopsy to obtain tissue for tumor genotyping. (See LCDs for Cancer for coverage guidelines.) Molecular Assays for Prostate Cancer, including but not limited to: • ConfirmMDx • Decipher® • Oncotype DX™ Prostate Cancer • PROGENSA® PCA3 Assay • Prolaris™ • ProMark® Risk Score (Refer to the LCDs for Cancer for coverage guidelines.) Transplant Recipients • AlloMap® Molecular Expression Testing is a non - invasive gene expression test used to aid in the identification of

heart transplant recipients.



• AlloSure® donor - derviced cell - free DNA is used to assess the probability of allograft rejection in kidney transplant recipients with clinical suspicion of rejection.

(Refer to the LCDs for Molecular Pathology section for coverage guidelines.) GeneSight® Assay for Refractory Depression GeneSight Psychotropic is a multiplex pharmacogenomic test involving the analysis of fifty alleles (SNPs) from six different genes. The test results in the differentiation of psychoactive drugs that are likely to be effective and well - tolerated by a particular patient versus those that are not. GeneSight testing may only be ordered by licensed psychiatrists contemplating an alteration in neuropsychiatric medication for patients diagnosed with major depressive disorder (MDD) after at least one prior neuropsychiatric medication failure. (See LCD for GeneSight in Miscellaneous section for coverage guidelines.) Assays for Rheumatoid Arthritis, including but not limited to: • The Avise® PG Assay • Vectra® DA (Refer to the Article section for coverage guidelines.) Genetic Testing for Myeloproliferative Disease Myeloproliferative disorders are a group of conditions that cause abnormal growth of blood cells in the bone marrow. They include polycythemia vera (PV), essential thrombocytosis (ET), primary myelofibrosis (PMF), and chronic myelogenous leukemia (CML). The World Health Organization (WHO) further classifies PV, ET, and PMF as Philadelphia chromosome negative myeloproliferative neoplasms (MPNs). MPNs are characterized by an increase in the number of blood cells. (See LCDs for Molecular Pathology for coverage guidelines.) Molecular RBC (Red Blood Cell) Phenotyping Molecular RBC Phenotyping is pretransfusion molecular testing using the HEA BeadChip™ assay for the following categories of patients: • Long term, frequent transfusions anticipated to prevent the development of alloantibodies (e.g., sickle cell anemia,

thalassemia or other reason); • Autoantibodies or other serologic reactivity that impedes the exclusion of clinically significant alloantibodies (e.g.,

autoimmune hemolytic anemia, warm autoantibodies, patient recently transfused with a positive DAT, high - titer low avidity antibodies, patients about to receive or on daratumumab therapy, other reactivity of no apparent cause);

• Suspected antibody against an antigen for which typing sera is not available; and • Laboratory discrepancies on serologic typing (e.g., rare Rh D antigen variants) (See LCDs for Molecular Pathology

for coverage guidelines.) Guidelines Based on the Centers for Medicare & Medicaid Services (CMS) Program Integrity Manual (100 - 08), this policy addresses the circumstances under which the item or service is reasonable and necessary under the Social Security Act, §1862(a)(1)(A). For laboratory services, a service can be reasonable and necessary if the service is safe and effective; and appropriate, including the duration and frequency that is considered appropriate for the item or service, in terms of whether it is furnished in accordance with accepted standards of medical practice for the diagnosis of the patient's condition; furnished in a setting appropriate to the patient's medical needs and condition; ordered and furnished by qualified personnel; one that meets, but does not exceed, the patient's medical need; and is at least as beneficial as an existing and available medically appropriate alternative. Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review. Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states " ...no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis and treatment of illness or injury...". Furthermore, it has been longstanding CMS policy that "tests that are performed in the absence of signs, symptoms, complaints, or personal history of disease or injury are not covered unless explicitly authorized by statute". Screening services, such as pre - symptomatic genetic tests and services, are those used to detect an undiagnosed disease or disease predisposition, and as such are not a Medicare benefit and not covered by Medicare. Similarly, Medicare may not reimburse the costs of tests/examinations that assess the risk for and/or of a condition unless the risk assessment clearly and directly effects the management of the patient. However, Medicare does cover a broad range of legislatively mandated preventive services to prevent disease, detect disease early when it is most treatable and curable, and manage disease so that complications can be avoided. These services can be found on the CMS website at http://www.cms.gov/PrevntionGenInfo/. Per 42 Code of Federal Regulations (CFR) section 410.32 (a) states the following requirements: All diagnostic x - rays tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem

http://www.cms.gov/PrevntionGenInfo/



and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary (see 411.15(k)(1)). Also, see Medicare Benefit Policy Manual (100 - 02), Chapter 15, Section 80.6 for related physician order instructions. Laboratory services must meet all applicable requirements of the Clinical Laboratory Improvement Amendments of 1988 (CLIA), as set forth at 42 CFR part 493. Section 1862(a)(1)(A) of the Act provides that Medicare payment may not be made for services that are not reasonable and necessary. Clinical laboratory services must be ordered and used promptly by the physician who is treating the beneficiary as described in 42 CFR 410.32(a), or by a qualified non - physician practitioner, as described in 42 CFR 410.32(a)(3). Many applications of the molecular pathology procedures are not covered services given lack of benefit category (preventive service) and/or failure to reach the reasonable and necessary threshold for coverage (based on quality of clinical evidence and strength of recommendation). Furthermore, payment of claims in the past (based on stacking codes) or in the future (based on the new code series) is not a statement of coverage since the service was not audited for compliance with program requirements and documentation supporting the reasonable and necessary testing for the beneficiary. Certain tests and procedures may be subject to prepayment medical review (records requested) and paid claims must be supportable, if selected, for post payment audit. Tests for diseases or conditions that manifest severe signs or symptoms in newborns and in early childhood or that result in early death (e.g., Canavan disease) could be subject to automatic denials since these tests are not usually relevant to a Medicare beneficiary. Documentation Guidelines Documentation must be adequate to verify that coverage guidelines listed above have been met. Thus, the medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed. The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition that warrants the test(s). Examples of documentation requirements of the ordering physician/non - physician practitioner (NPP) include, but are not limited to, history and physical or exam findings that support the decision making, problems/diagnoses, relevant data (e.g., lab testing, imaging results). Documentation requirements of the performing laboratory (when requested) include, but are not limited to, lab accreditation, test requisition, test record/procedures, reports (preliminary and final), and quality control record. Documentation requirements for lab developed tests/protocols (when requested) include diagnostic test/assay, lab/manufacturer, names of comparable assays/services (if relevant), description of assay, analytical validity evidence, clinical validity evidence, and clinical utility. Providers are required to code to specificity however, if an unlisted CPT code is used the documentation must clearly identify the unique procedure performed. When multiple procedure codes are submitted on a claim (unique and/or unlisted) the documentation supporting each code should be easily identifiable. If on review UnitedHealthcare cannot link a billed code to the documentation, these services will be denied. When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act. APPLICABLE CODES The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non - covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.

CPT/HCPCS Codes Molecular Pathology/Molecular Diagnostics/Genetic Testing: CPT/HCPCS Code List

ICD-10 Diagnosis Codes Refer to Molecular Pathology/Molecular Diagnostics/Genetic Testing: ICD - 10 Diagnosis Code List for ICD - 10 diagnosis codes for CPT codes 0045U, 0047U, 81170, 81175, 81176, 81201, 81203, 81235, 81261, 81263, 81272, 81292, 81295, 81298, 81310, 81314, 81321, 81323, 81334, 81335, 81340, 81342, 81345, 81490, 81519, 81522, 81525, 81538, 81540, 81542, 81545, 81552, 81595, 88120, and 88121.

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/attachments/medadv/molecular-pathology-diagnostics-genetic-testing-cpt-hcpcs-codes.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/attachments/medadv/molecular-pathology-diagnostics-genetic-testing-dx-codes.pdf



PURPOSE The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services. The document can be used as a guide to help determine applicable: • Medicare coding or billing requirements, and/or • Medical necessity coverage guidelines; including documentation requirements. UnitedHealthcare follows Medicare guidelines such as LCDs, NCDs, and other Medicare manuals for the purposes of determining coverage. It is expected providers retain or have access to appropriate documentation when requested to support coverage. Please utilize the links in the References section below to view the Medicare source materials used to develop this resource document. This document is not a replacement for the Medicare source materials that outline Medicare coverage requirements. Where there is a conflict between this document and Medicare source materials, the Medicare source materials will apply. REFERENCES

CMS National Coverage Determinations (NCDs)

NCD 90.2 Next Generation Sequencing (NGS) NCD 190.3 Cytogenetic Studies NCD 190.7 Human Tumor Stem Cell Drug Sensitivity Assays

CMS Local Coverage Determinations (LCDs) LCD Contractor Medicare Part A Medicare Part B

Immunohistochemistry, Drug Metabolism Testing, GeneSight for Depression, Topographic Genotyping for Pancreas L34554 (In Vitro Chemosensitivity & Chemoresistance Assays)

Palmetto GBA AL, GA, NC, SC, TN, VA, WV AL, GA, NC, SC, TN, VA, WV

L34864 (Loss – of - Heterozygosity Based Topographic Genotyping with PathfinderTG®/PancraGEN™)

Novitas Solutions, Inc.

AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX


L35072 (MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing)



CGS KY, OH KY, OH

L35443 (MolDX: GeneSight® Assay for Refractory Depression)

CGS KY, OH KY, OH



L35698 (CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing)

First Coast FL, PR, VI FL, PR, VI

L35922 (Lab: Special Histochemical Stains and Immunohistochemical Stains)


L35986 (Special Histochemical Stains and Immunohistochemical Stains)

CGS KY, OH KY, OH

L36234 (Special Histochemical Stains & Immunohistochemical Stains)



Noridian AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=372&ncdver=1&DocID=90.2&bc=gAAAABAAAAAA&

http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=198&ncdver=1&DocID=190.3&kq=true&bc=gAAAAAgAAAAAAA%3d%3d&

http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=253&ncdver=1&DocID=190.7&kq=true&bc=gAAAAAgAAAAAAA%3d%3d&

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34554&ver=25&Date=&DocID=L34554&bc=iAAAABABAAAA&
































LCD Contractor Medicare Part A Medicare Part B Immunohistochemistry, Drug Metabolism Testing, GeneSight for Depression, Topographic Genotyping for Pancreas


Noridian AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY

AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY












WPS AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY

IA, IN, KS, MI, MO, NE

L36634 (In Vitro Chemosensitivity & Chemoresistance Assays)










L37260 (MolDX: Prometheus IBD sgi Diagnostic Policy)


L37266 (MolDX: AlloSure® Donor - Derived Cell - Free DNA Test)










CGS KY, OH KY, OH





CGS KY, OH KY, OH






























https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37303&ver=8&DocID=L37303&bc=gAAAABABAAAA&












LCD Contractor Medicare Part A Medicare Part B Immunohistochemistry, Drug Metabolism Testing, GeneSight for Depression, Topographic Genotyping for Pancreas









Cancer Genetic Testing L33420 (Lab: Bladder/Urothelial Tumor Markers)


L33586 (Gene Expression Profiling Panel for use in the Management of Breast Cancer Treatment)


L33629 (Non - covered Services) NGS CT, IL, MA, ME, MN, NH, NY, RI, VT, WI

CT, IL, MA, ME, MN, NH, NY, RI, VT, WI

L33965 (Urinary Tumor Markers for Bladder Cancer)


L34912 (Genetic Testing for Lynch Syndrome)


L35024 (MolDX: Genetic Testing for Lynch Syndrome)


L35062 (Biomarkers Overview) Novitas Solutions, Inc.



L35073 (MolDX: NRAS Genetic Testing)



CGS KY, OH KY, OH

L35396 (Biomarkers for Oncology) Novitas Solutions, Inc.




CGS KY, OH KY, OH

L35631 (MolDX: Breast Cancer Index℠ Genetic Assay) Retired 03/10/2019 and replaced with L37794 (MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test)


L35632 (MolDX: ConfirmMDx Epigenetic Molecular Assay)


L35868 (MolDX: Decipher® Prostate Cancer Classifier Assay)


L35869 (MolDX: Prolaris™ Prostate Cancer Genomic Assay)


L35974 (MolDX: MGMT Promoter Methylation Analysis)



CGS KY, OH KY, OH

L36006 (MolDX - CDD: ConfirmMDx Epigenetic Molecular Assay)

CGS KY, OH KY, OH












https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33629&ver=33&Date=&DocID=L33629&bc=iAAAABAAAAAA&

















https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35632&ver=35&Date=01%2f01%2f2020&DocID=L35632&bc=iAAAABAAAAAA&








https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36002&ver=15&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=MolDX&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACABAAAA&






LCD Contractor Medicare Part A Medicare Part B Cancer Genetic Testing L36082 (MolDX: BRCA1 and BRCA2 Genetic Testing)



CGS KY, OH KY, OH

L36125 (MolDX: Breast Cancer Assay: Prosigna)


L36153 (MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay)


L36161 (MolDX: BRCA1 and BRCA2 Genetic Testing)











CGS KY, OH KY, OH








(L36339) MolDX: NRAS Genetic Testing





L36316 (MolDX: Breast Cancer Index?; Genetic Assay) Retired 04/15/2019 and replaced with (L37824) MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test




























































LCD Contractor Medicare Part A Medicare Part B Cancer Genetic Testing L36364 (MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay)










L36376 (Genomic Sequence Analysis Panels in the Treatment of Non - Small Cell Lung Cancer) Retired 03/31/2019. For DOS on or after 04/01/2019 refer to L37810 (Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms)

NGS CT, IL, MA, ME, MN, NH, NY, RI, VT, WI








CGS KY, OH KY, OH


CGS KY, OH KY, OH


CGS KY, OH KY, OH

L36499 (BRCA1 and BRCA2 Genetic Testing)



CGS KY, OH KY, OH

L36665 (MolDX: ProMark Risk Score)


L36675 (MolDX - CDD: ProMark Risk Score)

CGS KY, OH KY, OH

L36678 (Lab: Bladder/Urothelial Tumor Markers)


L36680 (Lab: Bladder/Urothelial Tumor Markers)





L36706 (MolDX: ProMark Score) Noridian AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY


L36715 (BRCA1 and BRCA2 Genetic Testing)




L36763 (MolDX: 4Kscore Assay) Palmetto GBA AL, GA, NC, SC, TN, VA, WV AL, GA, NC, SC, TN, VA, WV














https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36380&ver=20&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=prosigna&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACABAAAA&

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36380&ver=20&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=prosigna&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACABAAAA&





















https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36704&ver=15&DocType=Active&bc=AgIAAAABAAAA&








LCD Contractor Medicare Part A Medicare Part B Cancer Genetic Testing L36785 (MolDX: Breast Cancer Index℠ Genetic Assay) Retired 04/14/2019 replaced with L37913 (MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test)



L37913 (MolDX: Breast Cancer Index™ (BCI) Gene Expression Test)





















L36827 (MolDX: APC and MUTYH Gene Testing)























LCD Contractor Medicare Part A Medicare Part B Cancer Genetic Testing L36854 (MolDX: Percepta© Bronchial Genomic Classifier)







L36886 (MolDX: Percepta© Bronchial Genomic Classifier)






CGS KY, OH KY, OH


CGS KY, OH KY, OH

L36912 (MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™))








CGS KY, OH KY, OH

L36975 (Bladder/Urothelial Tumor Markers)

CGS KY, OH KY, OH

L37120 (MolDX: 4Kscore Assay) Noridian AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV L37122 (MolDX: 4Kscore Assay) Noridian AK, AZ, ID, MT, ND, OR, SD,

UT, WA, WY AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY

L36979 (MolDX: 4Kscore Assay) CGS KY, OH KY, OH L37001 (MolDX: MGMT Promoter Methylation Analysis)
















































LCD Contractor Medicare Part A Medicare Part B Cancer Genetic Testing L37013 (MolDX: 4Kscore Assay) WPS AK, AL, AR, AZ, CA, CO, CT,

DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY


L37033 (MolDX: DecisionDx - UM (Uveal Melanoma))







L37043 (MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease)








CGS KY, OH KY, OH





CGS KY, OH KY, OH











































LCD Contractor Medicare Part A Medicare Part B Cancer Genetic Testing L37210 (MolDX: Decision Dx - UM (Uveal Melanoma))






L37262 (MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer)


L37264 (MolDX: EndoPredict Breast Cancer Gene Expression Test)


L37295 (MolDX: EndoPredict® Breast Cancer Gene Expression Test)




L37311 (MolDX: EndoPredict® Breast Cancer Gene Expression Test)







CGS KY, OH KY, OH




L37356 (MolDX: EndoPredict Breast Cancer Gene Expression Test)

CGS KY, OH KY, OH

L37366 (MolDX: Guardant360® Plasma - Based Comprehensive Genomic Profiling in Non - Small Cell Lung Cancer (NSCLC))

CGS KY, OH KY, OH

L37606 (Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases)



































https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37356&ver=9&CntrctrSelected=239*1&Cntrctr=239&DocType=2&bc=AAACAAQBAAAA&

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37356&ver=9&CntrctrSelected=239*1&Cntrctr=239&DocType=2&bc=AAACAAQBAAAA&










LCD Contractor Medicare Part A Medicare Part B Cancer Genetic Testing L37649 (MolDX: Guardant360® Plasma - Based Comprehensive Genomic Profiling in Non - Small Cell Lung Cancer (NSCLC))










L37701 (MolDX: Oncotype DX AR - V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC))


L37725 (MolDX: DecisionDx - Melanoma)


L37733 (Biomarker Testing (Prior to Initial Biopsy) for Prostate Cancer Diagnosis)








L38029 (MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Intermediate Risk Disease)


L37785 (MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease)



CGS KY, OH KY, OH





































https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=38029&ver=5&DocID=L38029&bc=gAAAABAAAAAA&




https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37785&ver=10&CntrctrSelected=378*1&Cntrctr=378&LCntrctr=378*1%7c379*1%7c380*1%7c381*1&DocType=4&bc=AgACAAQBAAAA&




https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37834&ver=9&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=Decipher&KeyWordLookUp=Title&KeyWordSearchType=And&articleId=56906&Date=&bc=gAAAACABAAAA&




https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37911&ver=8&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=Decipher&KeyWordLookUp=Title&KeyWordSearchType=And&articleId=56906&Date=&bc=gAAAACAAAAAA&






LCD Contractor Medicare Part A Medicare Part B Cancer Genetic Testing L37792 (4Kscore Test Algorithm) Novitas

Solutions, Inc. AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX




L37822 (MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test)


L37824 (MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test)



L37798 (Non - covered Service - 4Kscore Test Algorithm) Effective 03/18/2019 - 01/05/2020


L37798 (4Kscore Test Algorithm) Effective 01/06/2020


L37810 (Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms)




CGS KY, OH KY, OH


CGS KY, OH KY, OH

L37851 (Biomarker Testing for Neuroendocrine Tumors/Neoplasms)



L37870 (MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer)


L37907 (MolDX: myPath Melanoma Assay)

CGS KY, OH KY, OH











L36143 (MolDX: NSCLC, Comprehensive Genomic Profile Testing) Retired 09/24/2018



CGS KY, OH KY, OH



https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37792&ver=16&DocType=4&bc=AAIAAAABAAAA&



https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37822&ver=6&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&CptHcpcsCode=81518&bc=gAAAACABAAAA&






https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37798&ver=13&DocType=4&bc=AgIAAAABAAAA&




https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37832&ver=9&CntrctrSelected=228*2&Cntrctr=228&name=&DocType=4&bc=AAACAAQBAAAA&
























LCD Contractor Medicare Part A Medicare Part B Cancer Genetic Testing L36198 (MolDX: NSCLC, Comprehensive Genomic Profile Testing) Retired 09/24/2018






L36926 (Genomic Sequence Analysis Panels in the Treatment of Acute Myelogenous Leukemia (AML)) Retired 07/31/2018



L37078 (Genomic Sequence Analysis Panels in the Treatment of Myelodysplastic Syndromes (MDS)) Retired 07/31/2018



Molecular Pathology L34519 (Molecular Pathology Procedures)


L35000 (Molecular Pathology Procedures)



L35025 (MolDX: Molecular Diagnostic Tests (MDT))




L35984 (MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR))

CGS KY, OH KY, OH

L36011 (MolDX: Molecular RBC Phenotyping)

CGS KY, OH KY, OH

L36021 (Molecular Diagnostic Tests (MDT))

CGS KY, OH KY, OH

L36044 (MolDX: Genetic Testing for BCR - ABL Negative Myeloproliferative Disease)







CGS KY, OH KY, OH


Noridian AS, CA GU, HI, MP, NV AS, CA GU, HI, MP, NV










































LCD Contractor Medicare Part A Medicare Part B Molecular Pathology L36167 (MolDX: Molecular RBC Phenotyping)













L36400 (MolDX: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR))












L37031 (MolDX: BDX - XL2) Palmetto GBA AL, GA, NC, SC, TN, VA, WV AL, GA, NC, SC, TN, VA, WV L37054 (MolDX: BDX - XL2) Noridian AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV L37062 (MolDX: BDX - XL2) Noridian AK, AZ, ID, MT, ND, OR, SD,


L37134 (MolDX: BDX - XL2) CGS KY, OH KY, OH L37216 (MolDX: BDX - XL2) WPS AK, AL, AR, AZ, CA, CO, CT,

DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY


L37857 (MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test)



































LCD Contractor Medicare Part A Medicare Part B Molecular Pathology L38053 (MolDX: TruGraf Blood Gene Expression Test)

CGS KY, OH KY, OH

L38160 MolDX: TruGraf Blood Gene Expression Test)



L38039 (MolDX: TruGraf Blood Gene Expression Test)


L38041 (MolDX: Prospera™) Future Effective 02/03/2020


L37612 (MolDX: Corus® CAD Assay) Palmetto GBA AL, GA, NC, SC, TN, VA, WV AL, GA, NC, SC, TN, VA, WV L37787 (MolDX: Corus® CAD Assay) CGS KY, OH KY, OH L37673 (MolDX: Corus® CAD Assay) Noridian AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV L37675 (MolDX: Corus® CAD Assay) Noridian AK, AZ, ID, MT, ND, OR, SD,


L37770 (MolDX: CORUS® CAD ASSAY)



L36713 (Corus® CAD Test) Novitas Solutions, Inc.



Circulating Tumor Cell Assays L34066 (MolDX: Circulating Tumor Cell Marker Assays)



(L35071 (MolDX: Circulating Tumor Cell Marker Assays)


L35710 (MolDX: Circulating Tumor Cell Marker Assays)


L36973 (MolDX: Circulating Tumor Cell Marker Assays)

CGS KY, OH KY, OH

L33279 (Circulating Tumor Cell Testing) Retired 05/25/2018


A55248 (MolDX: Approved Gene Testing) Retired 10/01/2018



CMS Articles Article Contractor Medicare Part A Medicare Part B

A57503 (Billing and Coding: MolDX: Testing of Multiple Genes)

Palmetto AL, GA, NC, SC, TN, VA, WV AL, GA, NC, SC, TN, VA, WV

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=38053&ver=3&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=TruGraf&KeyWordLookUp=Title&KeyWordSearchType=And&articleId=57446&bc=gAAAACAAAAAA&






















https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=57503&ver=7&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&CptHcpcsCode=81328&bc=gAAAACAAgAAA&




Article Contractor Medicare Part A Medicare Part B A57880 (Billing and Coding: MolDX: Testing of Multiple Genes)



A57910 (Billing and Coding: MolDX: Testing of Multiple Genes)

CGS KY, OH KY, OH

A53095 (Billing and Coding: Lab: Bladder/Urothelial Tumor Markers)


A53099 (Billing and Coding: MolDX: AlloMap)


A53100 (Billing and Coding: MolDX: Avise PG Assay)


A53101 (MolDX: bioTheranostics Cancer TYPE ID® Update)


A53103 (Billing and Coding: MolDX: HERmark® Assay by Monogram Update)


A53104 (Billing and Coding: MolDX: MammaPrint)


A53106 (MolDX: Oncotype DX® Colon Cancer Assay Update)


A53110 (Billing and Coding: MolDX: Vectra™ DA)


A53112 (Billing and Coding: MolDX: OncoCee™)


A53489 (Billing and Coding: MolDX: PreDx®)


A53493 (Billing and Coding: MolDX: HBB Gene Tests)


A53524 (Billing and Coding: MolDX: CYP2C9 and/or VKORC1 Gene Testing for Warfarin Response)


A53540 (Billing and Coding: MolDX: BLM Gene Analysis)


A53550 (Billing and Coding: MolDX: ATP7B Gene Tests)


A53596 (Billing and Coding: MolDX: IKBKAP Genetic Testing)


A53598 (Billing and Coding: MolDX: HEXA Gene Analysis)


A53600 (Billing and Coding: MolDX: BCKDHB Gene Test)


A53602 (Billing and Coding: MolDX: Aspartoacyclase 2 Deficiency (ASPA) Testing)


A53615 (Billing and Coding: MolDX: CFTR Gene Analysis)


A53628 (Billing and Coding: MolDX: FANCC Genetic Testing)


A53630 (Billing and Coding: MolDX: MCOLN1 Genetic Testing)


https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=57880&ver=2&LCDId=36807&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&CptHcpcsCode=81370&bc=gAAAACAAAAAA&

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=57880&ver=2&LCDId=36807&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&CptHcpcsCode=81370&bc=gAAAACAAAAAA&

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=57910&ver=2&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&CptHcpcsCode=81414&bc=gAAAACAAAAAA&


https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53095&ver=19&Date=&DocID=A53095&bc=hAAAABAAgAAA&













https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53106&ver=16&Date=&DocID=A53106&bc=hAAAABAAAAAA&






https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53489&ver=11&Cntrctr=All&UpdatePeriod=767&bc=AQAAEAAAgAAA&

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53489&ver=11&Cntrctr=All&UpdatePeriod=767&bc=AQAAEAAAgAAA&








https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53550&ver=19&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=ATP7B&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAgAAA&

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53550&ver=19&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&KeyWord=ATP7B&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAgAAA&


















Article Contractor Medicare Part A Medicare Part B A54832 (Billing and Coding: Short Tandem Repeat (STR) Markers and Chimerism (CPT® codes 81265 - 81268))


A54021 (Billing and Coding: MolDX: FDA - Approved EGFR Tests)


A54686 (Billing and Coding: MolDX: BCR - ABL)

CGS KY, OH KY, OH


CGS KY, OH KY, OH

A54191 (Billing and Coding: MolDX: FDA - Approved BRAF Tests)

CGS KY, OH KY, OH

A54192 (Billing and Coding: MolDX: FDA - Approved EGFR Tests)

CGS KY, OH KY, OH

A54264 (Billing and Coding: MolDX: Fragile X)

CGS KY, OH KY, OH

A54197 (Billing and Coding: MolDX: Progensa® PCA3 Assay Coverage Update)

CGS KY, OH KY, OH

A54200 (Billing and Coding: MolDX: therascreen® KRAS PCR Kit Guidelines)

CGS KY, OH KY, OH

A54240 (Bladder Tumor Marker FISH Billing and Coding Guidelines Update) Retired effective 12/23/2019 See A56471

CGS KY, OH KY, OH

A56471 (Billing and Coding: Bladder/Urothelial Tumor Markers)

CGS KY, OH KY, OH


CGS KY, OH KY, OH


CGS KY, OH KY, OH


CGS KY, OH KY, OH


CGS KY, OH KY, OH


CGS KY, OH KY, OH


CGS KY, OH KY, OH

A54275 (Billing and Coding: MolDX: LPA - Aspirin Genotype)

CGS KY, OH KY, OH


CGS KY, OH KY, OH

A54290 (Billing and Coding: MolDX: myPap™)

CGS KY, OH KY, OH


CGS KY, OH KY, OH

A54687 (Billing and Coding: MolDX: CYP2C9 and/or VKORC1 Gene Testing for Warfarin Response)

CGS KY, OH KY, OH

A54689 (Billing and Coding: MolDX: Myriad’s BRACAnalysis CDx™)

CGS KY, OH KY, OH

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54832&ver=10&Date=&DocID=A54832&SearchType=Advanced&bc=JAAAABAAgAAA&






















































Article Contractor Medicare Part A Medicare Part B A54830 (Billing and Coding: MolDX: Short Tandem Repeat (STR) Markers and Chimerism (codes 81265 - 81268))

CGS KY, OH KY, OH



A54356 (Billing and Coding: MolDX: Afirma™ Assay by Veracyte)


A54358 (Billing and Coding: MolDX: Afirma™ Assay by Veracyte)



A54363 (MolDX: AlloMap Billing and Coding Guidelines) Retired effective 11/01/2019 See A54364


A54364 (Billing and Coding: MolDX: AlloMap)







A54483 (MolDX: Oncotype DX® Colon Cancer Coding and Billing Guidelines) Retired effective 11/01/2019 See A54484


A54484 (Billing and Coding: MolDX: Oncotype DX® Colon Cancer)


A55243 (Billing and Coding: MolDX: GBA Genetic Testing)






CGS KY, OH KY, OH






A54472 (Billing and Coding: MolDX: FDA - Approved KRAS Tests)



CGS KY, OH KY, OH






A54835 (Billing and Coding: MolDX: CDH1 Genetic Testing)


A54878 (Billing and Coding: MolDX: CDH1 Genetic Testing)

CGS KY, OH KY, OH

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54830&ver=6&DocID=A54830&SearchType=Advanced&bc=IAAAABAAgAAA&

































https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54472&ver=22&DocType=Active%7cFuture&bc=AgCAAAAAgAAA&

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54472&ver=22&DocType=Active%7cFuture&bc=AgCAAAAAgAAA&













Article Contractor Medicare Part A Medicare Part B A55622 (Billing and Coding: MolDX: CDH1 Genetic Testing)



A55085 (Billing and Coding: MolDX: CHD7 Gene Analysis)


A55086 (MolDX: CHD7 Gene Analysis Coding and Billing Guidelines)







CGS KY, OH KY, OH



A55277 (Billing and Coding: MolDX: L1CAM Gene Sequencing)






CGS KY, OH KY, OH






A55716 (Billing and Coding: MolDX: Abbott RealTime IDH1 and IDH2 testing for Acute Myeloid Leukemia (AML))

CGS KY, OH KY, OH






A54253 (Billing and Coding: MolDX: Aspartoacyclase 2 Deficiency(ASPA) Testing)

CGS KY, OH KY, OH

A55094 (Billing and Coding: MolDX: ApoE Genotype)
















https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53565&ver=12&DocID=A53565&bc=gAAAABAAgAAA&































Article Contractor Medicare Part A Medicare Part B A55141 (Billing and Coding: MolDX: ApoE Genotype)






CGS KY, OH KY, OH






























































Article Contractor Medicare Part A Medicare Part B A55160 (Billing and Coding: MolDX: FANCC Genetic Testing)


















A55621 (Billing and Coding: MolDX: Short Tandem Repeat (STR) Markers and Chimerism (codes 81265 - 81268))



A55181 (Billing and Coding: MolDX: ENG and ACVRL1 Gene Tests)






CGS KY, OH KY, OH

























Article Contractor Medicare Part A Medicare Part B A55159 (Billing and Coding: MolDX: ENG and ACVRL1 Gene Tests)









































A55285 (MolDX: MECP2 Genetic Testing Billing and Coding Guidelines)


A55286 (MolDX: MECP2 Genetic Testing Billing and Coding Guidelines)



A54278 (Billing and Coding: MolDX: MECP2 Genetic Testing)

CGS KY, OH KY, OH











































Article Contractor Medicare Part A Medicare Part B A53574 (Billing and Coding: MolDX: MECP2 Genetic)


A55189 (Billing and Coding: MolDX: MECP2 Genetic Testing)



A55288 (Billing and Coding: MolDX: MMACHC Test)






CGS KY, OH KY, OH


















A55484 (Billing and Coding: MolDX: TP53 Gene Tests)


A55487 (Billing and Coding: MolDX: TP53 Gene Tests)



A54281 (Billing and Coding: MolDX: TP53 Gene Test)

CGS KY, OH KY, OH






A55597 (Billing and Coding: MolDX: PIK3CA Gene Tests)






CGS KY, OH KY, OH



































https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=55597&ver=13&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&CptHcpcsCode=0155u&bc=gAAAACAAAAAA&








Article Contractor Medicare Part A Medicare Part B A53558 (Billing and Coding: MolDX: PIK3CA Gene Tests)








A55609 (Billing and Coding: MolDX: NSD1 Gene Tests)






CGS KY, OH KY, OH






A55610 (Billing and Coding: MolDX: RPS19 Gene Tests)






CGS KY, OH KY, OH






A55480 (Billing and Coding: MolDX: STAT3 Gene Testing)






CGS KY, OH KY, OH












































Article Contractor Medicare Part A Medicare Part B A55612 (Billing and Coding: MolDX: IKBKAP Genetic Testing)





A55623 (Billing and Coding: MolDX: SEPT9 Gene Test)





A54300 (Billing and Coding: MolDx: SEPT9 Gene Test)

CGS KY, OH KY, OH






A55626 (Billing and Coding: MolDX: SLCO1B1 Genotype)









CGS KY, OH KY, OH



A55627 (Billing and Coding: MolDX: SMPD1 Genetic Testing)






CGS KY, OH KY, OH






A55482 (Billing and Coding: MolDX: UGT1A1 Gene Analysis)






CGS KY, OH KY, OH











































Article Contractor Medicare Part A Medicare Part B A55222 (Billing and Coding: MolDX: UGT1A1 Gene Analysis)





A53848 (Pharmacogenomic Testing for Warfarin Response)


A55822 (Billing and Coding: MolDX: ThermoFisher Oncomine Dx Target Test For Non - Small Cell Lung Cancer)






CGS KY, OH KY, OH






A56071 (Billing and Coding: In Vitro Chemosensitivity Assays)


A56072 (Billing and Coding: MolDX: Microsatellite Instability - High (MSI - H) and Mismatch Repair Deficient (dMMR) Biomarker for Patients with Unresectable or Metastatic Solid Tumors)


A56073 (Billing and Coding: In Vitro Chemosensitivity Assays)



A56871 (Billing and Coding: In Vitro Chemosensitivity & Chemoresistance Assays)


A56103 (Billing and Coding: MolDX: Microsatellite Instability - High (MSI - H) and Mismatch Repair Deficient (dMMR) Biomarker Billing and Coding Guidelines for Patients with Unresectable or Metastatic Solid Tumors)






https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53848&ver=2&DocID=A53848&bc=gAAAABAAAAAA&

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53848&ver=2&DocID=A53848&bc=gAAAABAAAAAA&































https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=56871&ver=6&Cntrctr=381&name=&DocType=Active&ContrVer=1&CntrctrSelected=381*1&LCntrctr=373*1%7c374*1%7c378*1%7c375*1%7c379*1%7c376*1%7c380*1%7c377*1%7c381*1&bc=AgABAAIAgAAA












Article Contractor Medicare Part A Medicare Part B A56104 (Billing and Coding: MolDX: Microsatellite Instability - High (MSI - H) and Mismatch Repair Deficient (dMMR) Biomarker Billing and Coding Guidelines for Patients with Unresectable or Metastatic Solid Tumors)




CGS KY, OH KY, OH

A56199 (Billing and Coding: Molecular Pathology Procedures)



A56270 (Billing and Coding: MolDX: Clonoseq® Assay for Assessment of Minimal Residual Disease (MRD) in Patients with Specific Lymphoid Malignancies)




A56307 (Billing and Coding: MolDX: Clonoseq® Assay for Assessment of Minimal Residual Disease (MRD) in Patients with Specific Lymphoid Malignancies)

CGS KY, OH KY, OH




A56882 (Billing and Coding: MolDX: Genetic Testing for Lynch Syndrome)

CGS KY, OH KY, OH

A57031 (Billing and Coding: MolDX: ConfirmMDx Epigenetic Molecular Assay)

CGS KY, OH KY, OH


CGS KY, OH KY, OH




CMS Benefit Policy Manual Chapter 15; § 80.1–80.1.3 Clinical Laboratory Services

CMS Claims Processing Manual Chapter 12; § 60 Payment for Pathology Services Chapter 16, § 10.2 General Explanation of Payment; § 20 Calculation of Payment Rates - Clinical Laboratory Test Fee Schedules; § 40 Billing for Clinical Laboratory Tests








































https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54292&ver=15&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&CptHcpcsCode=86153&Date=&bc=gAAAACAAAAAA&

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54292&ver=15&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&CptHcpcsCode=86153&Date=&bc=gAAAACAAAAAA&



https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c16.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c16.pdf



CMS Transmittals Transmittal 214, Change Request 10878, Dated 03/06/2019 (National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)) Transmittal 215, Change Request 10878, Dated 04/10/2019 (National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)) Transmittal 2200, Change Request 10859, Dated 11/08/2018 (International Classification of Diseases, Tenth Revision (ICD - 10) and Other Coding Revisions to National Coverage Determinations (NCDs))

UnitedHealthcare Commercial Policies Carrier Testing for Genetic Diseases Chemosensitivity and Chemoresistance Assays in Cancer Chromosome Microarray Testing (Non - Oncology Conditions) Fetal Aneuploidy Testing Using Cell - Free Fetal Nucleic Acids In Maternal Blood Genetic Testing for Cardiac Disease Genetic Testing for Hereditary Cancer Genetic Testing for Neuromuscular Disorders Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions Pharmacogenetic Testing Preimplantation Genetic Testing Whole Exome and Whole Genome Sequencing

Others CMS Clinical Laboratory Fee Schedule, CMS Website Palmetto GBA MolDx Website GUIDELINE HISTORY/REVISION INFORMATION Revisions to this summary document do not in any way modify the requirement that services be provided and documented in accordance with the Medicare guidelines in effect on the date of service in question.

Date Action/Description

01/08/2020

Related Policies • Updated list of related Medicare Advantage Policy Guidelines:

o Added reference link to the policy titled: Biomarkers in Cardiovascular Risk Assessment Molecular Pathology Procedures for Human Leukocyte Antigen (HLA)

Typing (new) Tier 2 Molecular Pathology Procedures (new)

o Removed reference link to the policy titled: Corus® CAD (Coronary Artery Disease) (retired)

Policy Summary Molecular Pathology Procedures for Human Leukocyte Antigen (HLA) Typing • Removed content pertaining to Molecular Pathology Procedures for (HLA) Typing;

refer to the Medicare Advantage Policy Guideline titled Molecular Pathology Procedures for Human Leukocyte Antigen (HLA) Typing for applicable details

Documentation Guidelines • Replaced reference to “contractor” with “UnitedHealthcare” Applicable Codes CPT Codes • Added 0084U, 0085U, 0087U, 0088U, 0089U, 0090U, 0091U, 0092U, 0093U,

0094U, 0095U, 0101U, 0102U, 0103U, 0104U, 0105U, 0108U, 0111U, 0113U, 0114U, 0118U, 0120U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0153U, 0154U, 0155U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 81246, 81277, 81307, 81308, 81309, 81493, 81522, 81542, and 81552

• Added notation to indicate: o 0009M “expired Dec. 31, 2019” o 0061U was “removed Jan. 8, 2020” o 0081U was “deleted Dec. 31, 2019” o 81211, 81213, and 81214 were “deleted Dec. 31, 2018”

• Revised description for 0006U, 0008U, and 81350 • Removed 81439 • Removed and relocated:

o 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379,

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R214NCD.pdf




https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2200OTN.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2200OTN.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/carrier-testing-for-genetic-diseases.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/carrier-testing-for-genetic-diseases.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/chemosensitivity-chemoresistance-assays-cancer.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/chromosome-microarray-testing.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/fetal-aneuploidy-testing-using-cell-free-nucleic-acids-maternal-blood.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/genetic-testing-cardiac-disease.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/genetic-testing-hereditary-breast-ovarian-cancer-syndrome.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/genetic-testing-neuromuscular-disorders.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/molecular-oncology-testing-for-cancer.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/pharmacogenetic-testing.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/preimplantation-genetic-testing.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/whole-exome-and-whole-genome-sequencing.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files

https://www.palmettogba.com/palmetto/MolDX.nsf/DocsCatHome/MolDx



Date Action/Description 81380, 81381, 81382, and 81383; refer to the UnitedHealthcare Medicare Advantage Policy titled Molecular Pathology Procedures for Human Leukocyte Antigen (HLA) Typing

o 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, and 81408; refer to the Medicare Advantage Policy Guideline titled Tier 2 Molecular Pathology Procedures

Modifiers • Removed modifier TC ICD-10 Diagnosis Codes Covered CPT Code 0045U • Added D05.11 and D05.12 CPT Code 81120 and 81121 • Removed list of applicable ICD-10 codes CPT Code 81522 • Added C50.011, C50.012, C50.111, C50.112, C50.211, C50.212, C50.311,

C50.312, C50.411, C50.412, C50.511, C50.512, C50.611, C50.612, C50.811, C50.812, C50.911, and C50.912

CPT Code 81540 • Updated notation to indicate C18.1, C22.2, C22.3, C22.4, D01.5, D01.7, D01.9,

D02.21, D02.22, D03.51, D03.52 and D03.59 were “removed July, 14, 2019” CPT Code 81552 • Added C69.31, C69.32, C69.41, C69.42, C69 .91 and, C69.92 CPT Code 88367 and 88368 • Deleted ICD-10 codes previously notated as "expired Feb. 28, 2018" Non-Covered • Added Z11.7 Supporting Information • Updated References section to reflect the most current information

TERMS AND CONDITIONS The Medicare Advantage Policy Guidelines are applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates. These Policy Guidelines are provided for informational purposes, and do not constitute medical advice. Treating physicians and healthcare providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care. Benefit coverage for health services is determined by the member specific benefit plan document* and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes the Medicare Advantage Policy Guidelines. Medicare Advantage Policy Guidelines are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. UnitedHealthcare may modify these Policy Guidelines at any time by publishing a new version of the policy on this website. Medicare source materials used to develop these guidelines include, but are not limited to, CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Medicare Benefit Policy Manual, Medicare Claims Processing Manual, Medicare Program Integrity Manual, Medicare Managed Care Manual, etc. The information presented in the Medicare Advantage Policy Guidelines is believed to be accurate and current as of the date of publication, and is provided on an "AS IS" basis. Where there is a conflict between this document and Medicare source materials, the Medicare source materials will apply. You are responsible for submission of accurate claims. Medicare Advantage Policy Guidelines are intended to ensure that coverage decisions are made accurately based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Medicare Advantage Policy Guidelines use Current Procedural Terminology (CPT®), Centers for Medicare and Medicaid Services (CMS), or other coding guidelines. References to CPT® or other sources are for definitional purposes only and do not imply any right to reimbursement or guarantee claims payment.



Medicare Advantage Policy Guidelines are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited. *For more information on a specific member's benefit coverage, please call the customer service number on the back of the member ID card or refer to the Administrative Guide. C 0 2 . 1 C 0 8 . 9 C 0 9 . 9 C 1 1 . 8 C 1 5 . 3 C 1 5 . 4 C 1 5 . 5 C 1 5 . 9 C 1 6 . 0 C 1 6 . 1 C 1 6 . 2 C 1 6 . 3 C 1 6 . 4 C 1 6 . 5 C 1 6 . 6 C 1 6 . 8 C 1 6 . 9 C 1 7 . 0 C 1 7 . 1 C 1 7 . 2 C 1 7 . 3 C 1 7 . 8 C 1 7 . 9 C 1 8 . 0 C 1 8 . 1 C 1 8 . 2 C 1 8 . 3 C 1 8 . 4 C 1 8 . 5 C 1 8 . 6

C 1 8 . 7 C 1 8 . 8 C 1 8 . 9 C 1 9 C 2 0 C 2 1 . 0 C 2 1 . 1 C 2 1 . 2 C 2 1 . 8 C 2 2 . 0 C 2 2 . 1 C 2 2 . 2 C 2 2 . 3 C 2 2 . 4 C 2 2 . 7 C 2 2 . 8 C 2 2 . 9 C 2 3 C 2 4 . 0 C 2 4 . 8 C 2 4 . 9 C 2 5 . 0 C 2 5 . 1 C 2 5 . 2 C 2 5 . 3 C 2 5 . 4 C 2 5 . 7 C 2 5 . 8 C 2 5 . 9 C 2 6 . 9 C 3 1 . 9 C 3 2 . 0 C 3 2 . 8 C 3 3 C 3 4 . 0 0 C 3 4 . 0 1 C 3 4 . 0 2 C 3 4 . 1 0 C 3 4 . 1 1 C 3 4 . 1 2 C 3 4 . 2 C 3 4 . 3 0 C 3 4 . 3 1 C 3 4 . 3 2 C 3 4 . 8 0 C 3 4 . 8 1 C 3 4 . 8 2 C 3 4 . 9 0 C 3 4 . 9 1 C 3 4 . 9 2 C 3 7 C 3 8 . 3 C 3 8 . 4 C 4 0 . 0 1 C 4 0 . 0 2 C 4 1 . 2 C 4 1 . 3 C 4 1 . 9

C 4 3 . 0 C 4 3 . 1 0 C 4 3 . 1 1 1 C 4 3 . 1 1 2 C 4 3 . 1 2 1 C 4 3 . 1 2 2 C 4 3 . 2 0 C 4 3 . 2 1 C 4 3 . 2 2 C 4 3 . 3 0 C 4 3 . 3 1 C 4 3 . 3 9 C 4 3 . 4 C 4 3 . 5 1 C 4 3 . 5 2 C 4 3 . 5 9 C 4 3 . 6 0 C 4 3 . 6 1 C 4 3 . 6 2 C 4 3 . 7 0 C 4 3 . 7 1 C 4 3 . 7 2 C 4 3 . 8 C 4 3 . 9 C 4 4 . 2 2 2 C 4 4 . 2 2 9 C 4 4 . 3 2 9 C 4 4 . 3 9 9 C 4 4 . 4 2 C 4 4 . 4 9 C 4 4 . 5 0 1 C 4 4 . 5 0 9 C 4 4 . 5 2 1 C 4 4 . 5 2 9 C 4 4 . 5 9 9 C 4 4 . 6 2 2 C 4 4 . 6 2 9 C 4 4 . 7 0 9 C 4 4 . 9 0 C 4 4 . 9 2 C 4 5 . 0 C 4 5 . 1 C 4 5 . 7 C 4 5 . 9 C 4 7 . 0 C 4 7 . 9 C 4 8 . 0 C 4 8 . 1 C 4 8 . 2 C 4 8 . 8 C 4 9 . 0 C 4 9 . 1 2 C 4 9 . 5 C 4 9 . 9 C 4 9 . A 0 C 4 9 . A 1 C 4 9 . A 2 C 4 9 . A 3

C 4 9 . A 4 C 4 9 . A 5 C 4 9 . A 9 C 4 A . 7 1 C 4 A . 9 C 5 0 . 0 1 1 C 5 0 . 0 1 2 C 5 0 . 0 1 9 C 5 0 . 0 2 1 C 5 0 . 0 2 2 C 5 0 . 0 2 9 C 5 0 . 1 1 1 C 5 0 . 1 1 2 C 5 0 . 1 1 9 C 5 0 . 1 2 1 C 5 0 . 1 2 2 C 5 0 . 1 2 9 C 5 0 . 2 1 1 C 5 0 . 2 1 2 C 5 0 . 2 1 9 C 5 0 . 2 2 1 C 5 0 . 2 2 2 C 5 0 . 2 2 9 C 5 0 . 3 1 1 C 5 0 . 3 1 2 C 5 0 . 3 1 9 C 5 0 . 3 2 1 C 5 0 . 3 2 2 C 5 0 . 3 2 9 C 5 0 . 4 1 1 C 5 0 . 4 1 2 C 5 0 . 4 1 9 C 5 0 . 4 2 1 C 5 0 . 4 2 2 C 5 0 . 4 2 9 C 5 0 . 5 1 1 C 5 0 . 5 1 2 C 5 0 . 5 1 9 C 5 0 . 5 2 1 C 5 0 . 5 2 2 C 5 0 . 5 2 9 C 5 0 . 6 1 1 C 5 0 . 6 1 2 C 5 0 . 6 1 9 C 5 0 . 6 2 1 C 5 0 . 6 2 2 C 5 0 . 6 2 9 C 5 0 . 8 1 1 C 5 0 . 8 1 2 C 5 0 . 8 1 9 C 5 0 . 8 2 1 C 5 0 . 8 2 2 C 5 0 . 8 2 9 C 5 0 . 9 1 1 C 5 0 . 9 1 2 C 5 0 . 9 1 9 C 5 0 . 9 2 1 C 5 0 . 9 2 2

C 5 0 . 9 2 9 C 5 3 . 0 C 5 3 . 8 C 5 3 . 9 C 5 4 . 0 C 5 4 . 1 C 5 4 . 2 C 5 4 . 3 C 5 4 . 8 C 5 4 . 9 C 5 5 C 5 6 . 1 C 5 6 . 2 C 5 6 . 9 C 5 7 . 0 0 C 5 7 . 0 1 C 5 7 . 0 2 C 5 7 . 1 0 C 5 7 . 1 1 C 5 7 . 1 2 C 5 7 . 2 0 C 5 7 . 2 1 C 5 7 . 2 2 C 5 7 . 3 C 5 7 . 4 C 5 7 . 8 C 5 7 . 9 C 6 1 C 6 4 . 1

C 6 4 . 2 C 6 4 . 9 C 6 5 . 1 C 6 5 . 2 C 6 5 . 9 C 6 6 . 1 C 6 6 . 2 C 6 6 . 9 C 6 7 . 0 C 6 7 . 1 C 6 7 . 2 C 6 7 . 3 C 6 7 . 4 C 6 7 . 5 C 6 7 . 6 C 6 7 . 7 C 6 7 . 8 C 6 7 . 9 C 6 8 . 0 C 6 8 . 1 C 6 8 . 8 C 6 8 . 9 C 6 9 . 3 1 C 6 9 . 3 2 C 6 9 . 4 1 C 6 9 . 4 2 C 6 9 . 9 1 C 6 9 . 9 2 C 7 1 . 0 C 7 1 . 1 C 7 1 . 2 C 7 1 . 3 C 7 1 . 4 C 7 1 . 5 C 7 1 . 6 C 7 1 . 7 C 7 1 . 8 C 7 1 . 9 C 7 3 C 7 4 . 9 0 C 7 4 . 9 2 C 7 5 . 1 C 7 6 . 0 C 7 6 . 2 C 7 6 . 3 C 7 6 . 5 1 C 7 6 . 5 2 C 7 6 . 8 C 7 7 . 0 C 7 7 . 1 C 7 7 . 2 C 7 7 . 3 C 7 7 . 4 C 7 7 . 5 C 7 7 . 8 C 7 7 . 9 C 7 8 . 0 0 C 7 8 . 0 1

C 7 8 . 0 2 C 7 8 . 1 C 7 8 . 2 C 7 8 . 4 C 7 8 . 5 C 7 8 . 6 C 7 8 . 7 C 7 8 . 8 0 C 7 8 . 8 9 C 7 9 . 0 1 C 7 9 . 0 2 C 7 9 . 2 C 7 9 . 3 1 C 7 9 . 4 9 C 7 9 . 5 1 C 7 9 . 5 2 C 7 9 . 6 0 C 7 9 . 6 1 C 7 9 . 6 2 C 7 9 . 7 0 C 7 9 . 7 1 C 7 9 . 7 2 C 7 9 . 8 1 C 7 9 . 8 2 C 7 9 . 8 9 C 7 9 . 9 C 7 A . 0 0 C 7 A . 0 1 0 C 7 A . 0 1 1 C 7 A . 0 1 2 C 7 A . 0 1 9 C 7 A . 0 2 0 C 7 A . 0 2 1 C 7 A . 0 2 2 C 7 A . 0 2 3 C 7 A . 0 2 4 C 7 A . 0 2 5 C 7 A . 0 2 6 C 7 A . 0 2 9 C 7 A . 0 9 0 C 7 A . 0 9 1 C 7 A . 0 9 2 C 7 A . 0 9 3 C 7 A . 0 9 4 C 7 A . 0 9 5 C 7 A . 0 9 6 C 7 A . 0 9 8 C 7 A . 1 C 7 A . 8 C 7 B . 0 0 C 7 B . 0 1 C 7 B . 0 2 C 7 B . 0 3 C 7 B . 0 4 C 7 B . 0 9 C 7 B . 1 C 7 B . 8 C 8 0 . 0

C 8 0 . 1 C 8 1 . 9 0 C 8 2 . 0 0 C 8 2 . 0 1 C 8 2 . 0 2 C 8 2 . 0 3 C 8 2 . 0 4 C 8 2 . 0 5 C 8 2 . 0 6 C 8 2 . 0 7 C 8 2 . 0 8 C 8 2 . 0 9 C 8 2 . 1 0 C 8 2 . 1 1 C 8 2 . 1 2 C 8 2 . 1 3 C 8 2 . 1 4 C 8 2 . 1 5 C 8 2 . 1 6 C 8 2 . 1 7 C 8 2 . 1 8 C 8 2 . 1 9 C 8 2 . 2 0 C 8 2 . 2 1 C 8 2 . 2 2 C 8 2 . 2 3 C 8 2 . 2 4 C 8 2 . 2 5 C 8 2 . 2 6 C 8 2 . 2 7 C 8 2 . 2 8 C 8 2 . 2 9 C 8 2 . 3 0 C 8 2 . 3 1 C 8 2 . 3 2 C 8 2 . 3 3 C 8 2 . 3 4 C 8 2 . 3 5 C 8 2 . 3 6 C 8 2 . 3 7 C 8 2 . 3 8 C 8 2 . 3 9 C 8 2 . 4 0 C 8 2 . 4 1 C 8 2 . 4 2 C 8 2 . 4 3 C 8 2 . 4 4 C 8 2 . 4 5 C 8 2 . 4 6 C 8 2 . 4 7 C 8 2 . 4 8 C 8 2 . 4 9 C 8 2 . 5 0 C 8 2 . 5 1 C 8 2 . 5 2 C 8 2 . 5 3 C 8 2 . 5 4 C 8 2 . 5 5

C 8 2 . 5 6 C 8 2 . 5 7 C 8 2 . 5 8 C 8 2 . 5 9 C 8 2 . 6 0 C 8 2 . 6 1 C 8 2 . 6 2 C 8 2 . 6 3 C 8 2 . 6 4 C 8 2 . 6 5 C 8 2 . 6 6 C 8 2 . 6 7 C 8 2 . 6 8 C 8 2 . 6 9 C 8 2 . 8 0 C 8 2 . 8 1 C 8 2 . 8 2 C 8 2 . 8 3 C 8 2 . 8 4 C 8 2 . 8 5 C 8 2 . 8 6 C 8 2 . 8 7 C 8 2 . 8 8 C 8 2 . 8 9 C 8 2 . 9 0 C 8 2 . 9 1 C 8 2 . 9 2 C 8 2 . 9 3 C 8 2 . 9 4 C 8 2 . 9 5 C 8 2 . 9 6 C 8 2 . 9 7 C 8 2 . 9 8 C 8 2 . 9 9 C 8 3 . 0 0 C 8 3 . 0 1 C 8 3 . 0 2 C 8 3 . 0 3 C 8 3 . 0 4 C 8 3 . 0 5 C 8 3 . 0 6 C 8 3 . 0 7 C 8 3 . 0 8 C 8 3 . 0 9 C 8 3 . 1 0 C 8 3 . 1 1 C 8 3 . 1 2 C 8 3 . 1 3 C 8 3 . 1 4 C 8 3 . 1 5 C 8 3 . 1 6 C 8 3 . 1 7 C 8 3 . 1 8 C 8 3 . 1 9 C 8 3 . 3 0 C 8 3 . 3 1 C 8 3 . 3 2 C 8 3 . 3 3

C 8 3 . 3 4 C 8 3 . 3 5 C 8 3 . 3 6 C 8 3 . 3 7 C 8 3 . 3 8 C 8 3 . 3 9 C 8 3 . 5 0 C 8 3 . 5 1 C 8 3 . 5 2 C 8 3 . 5 3 C 8 3 . 5 4 C 8 3 . 5 5 C 8 3 . 5 6 C 8 3 . 5 7 C 8 3 . 5 8 C 8 3 . 5 9 C 8 3 . 7 0 C 8 3 . 7 1 C 8 3 . 7 2 C 8 3 . 7 3 C 8 3 . 7 4 C 8 3 . 7 5 C 8 3 . 7 6 C 8 3 . 7 7 C 8 3 . 7 8 C 8 3 . 7 9 C 8 3 . 8 0 C 8 3 . 8 1 C 8 3 . 8 2 C 8 3 . 8 3 C 8 3 . 8 4 C 8 3 . 8 5 C 8 3 . 8 6 C 8 3 . 8 7 C 8 3 . 8 8 C 8 3 . 8 9 C 8 3 . 9 0 C 8 3 . 9 1 C 8 3 . 9 2 C 8 3 . 9 3 C 8 3 . 9 4 C 8 3 . 9 5 C 8 3 . 9 6 C 8 3 . 9 7 C 8 3 . 9 8 C 8 3 . 9 9 C 8 4 . 9 7 C 8 4 . A 7 C 8 4 . Z 7 C 8 5 . 1 0 C 8 5 . 1 1 C 8 5 . 1 2 C 8 5 . 1 3 C 8 5 . 1 4 C 8 5 . 1 5 C 8 5 . 1 6 C 8 5 . 1 7 C 8 5 . 1 8

C 8 5 . 1 9 C 8 5 . 2 0 C 8 5 . 2 1 C 8 5 . 2 2 C 8 5 . 2 3 C 8 5 . 2 4 C 8 5 . 2 5 C 8 5 . 2 6 C 8 5 . 2 7 C 8 5 . 2 8 C 8 5 . 2 9 C 8 5 . 8 0 C 8 5 . 8 1 C 8 5 . 8 2 C 8 5 . 8 3 C 8 5 . 8 4 C 8 5 . 8 5 C 8 5 . 8 6 C 8 5 . 8 7 C 8 5 . 8 8 C 8 5 . 8 9 C 8 5 . 9 0 C 8 5 . 9 1 C 8 5 . 9 2 C 8 5 . 9 3 C 8 5 . 9 4 C 8 5 . 9 5 C 8 5 . 9 6 C 8 5 . 9 7 C 8 5 . 9 8 C 8 5 . 9 9 C 8 6 . 1 C 8 8 . 4 C 8 8 . 8 C 9 1 . 0 0 C 9 1 . 0 1 C 9 1 . 0 2 C 9 1 . 1 0 C 9 1 . 1 1 C 9 1 . 1 2 C 9 1 . 3 0 C 9 1 . 4 0 C 9 1 . 4 1 C 9 1 . 4 2 C 9 1 . 5 0 C 9 1 . 6 0 C 9 1 . 6 1 C 9 1 . 6 2 C 9 1 . A 0 C 9 1 . Z 0 C 9 2 . 0 0 C 9 2 . 0 1 C 9 2 . 0 2 C 9 2 . 1 0 C 9 2 . 1 1 C 9 2 . 1 2 C 9 2 . 2 0 C 9 2 . 2 1

C 9 2 . 2 2 C 9 2 . 3 0 C 9 2 . 3 2 C 9 2 . 4 0 C 9 2 . 4 1 C 9 2 . 4 2 C 9 2 . 5 0 C 9 2 . 5 1 C 9 2 . 5 2 C 9 2 . 6 0 C 9 2 . 6 1 C 9 2 . 6 2 C 9 2 . 9 0 C 9 2 . 9 2 C 9 2 . A 0 C 9 2 . A 1 C 9 2 . A 2 C 9 2 . Z 0 C 9 2 . Z 2 C 9 3 . 0 0 C 9 3 . 0 2 C 9 3 . 1 0 C 9 3 . 1 1 C 9 3 . 1 2 C 9 3 . 9 0 C 9 3 . 9 2 C 9 3 . Z 0 C 9 3 . Z 2 C 9 4 . 0 0 C 9 4 . 0 2 C 9 4 . 4 0 C 9 4 . 4 1 C 9 4 . 4 2 C 9 4 . 6 C 9 4 . 8 0 C 9 4 . 8 2 C 9 5 . 0 0 C 9 5 . 0 2 C 9 5 . 1 0 C 9 5 . 1 2 C 9 5 . 9 0 C 9 5 . 9 1 C 9 5 . 9 2 C 9 6 . 2 0 C 9 6 . 2 1 C 9 6 . 2 2 C 9 6 . 2 9 C 9 6 . 9 C 9 6 . Z D 0 1 . 5 D 0 1 . 7 D 0 1 . 9 D 0 2 . 2 1 D 0 2 . 2 2 D 0 3 . 0 D 0 3 . 1 0 D 0 3 . 1 1 1 D 0 3 . 1 1 2

D 0 3 . 1 2 1 D 0 3 . 1 2 2 D 0 3 . 2 0 D 0 3 . 2 1 D 0 3 . 2 2 D 0 3 . 3 0 D 0 3 . 3 9 D 0 3 . 4 D 0 3 . 5 1 D 0 3 . 5 2 D 0 3 . 5 9 D 0 3 . 6 0 D 0 3 . 6 1 D 0 3 . 6 2 D 0 3 . 7 0 D 0 3 . 7 1 D 0 3 . 7 2 D 0 3 . 8 D 0 3 . 9 D 0 5 . 0 0 D 0 5 . 0 1 D 0 5 . 0 2 D 0 5 . 1 0 D 0 5 . 1 1 D 0 5 . 1 2 D 0 5 . 8 0 D 0 5 . 8 1 D 0 5 . 8 2 D 0 5 . 9 0 D 0 5 . 9 1 D 0 5 . 9 2 D 0 9 . 0 D 1 2 . 0 D 1 2 . 1 D 1 2 . 2 D 1 2 . 3 D 1 2 . 4 D 1 2 . 5 D 1 2 . 6 D 1 2 . 7 D 1 2 . 8 D 2 9 . 1 D 3 4 D 3 7 . 6 D 3 7 . 8 D 3 7 . 9 D 3 8 . 1 D 3 8 . 3 D 3 A . 0 1 0 D 3 A . 0 1 1 D 3 A . 0 1 2 D 3 A . 0 1 9 D 3 A . 0 2 0 D 3 A . 0 2 1 D 3 A . 0 2 2 D 3 A . 0 2 3 D 3 A . 0 2 4 D 3 A . 0 2 5

D 3 A . 0 2 6 D 3 A . 0 2 9 D 3 A . 0 9 0 D 3 A . 0 9 1 D 3 A . 0 9 2 D 3 A . 0 9 3 D 3 A . 0 9 4 D 3 A . 0 9 5 D 3 A . 0 9 6 D 3 A . 0 9 8 D 3 A . 8 D 4 0 . 0 D 4 1 . 0 1 D 4 1 . 4 D 4 4 . 0 D 4 4 . 9 D 4 5 D 4 6 . 0 D 4 6 . 1 D 4 6 . 2 0 D 4 6 . 2 1 D 4 6 . 2 2 D 4 6 . 4 D 4 6 . 9 D 4 6 . A D 4 6 . B D 4 6 . C D 4 6 . Z D 4 7 . 0 1 D 4 7 . 0 2 D 4 7 . 0 9 D 4 7 . 1 D 4 7 . 3 D 4 7 . 4 D 4 7 . 9 D 4 7 . Z 9 D 4 8 . 0 D 4 8 . 1 D 4 8 . 2 D 4 8 . 3 D 4 8 . 4 D 4 8 . 5 D 4 8 . 6 1 D 4 8 . 6 2 D 4 9 . 0 D 4 9 . 1 D 4 9 . 2 D 4 9 . 3 D 4 9 . 4 D 4 9 . 5 1 1 D 4 9 . 5 1 2 D 4 9 . 5 9 D 4 9 . 6 D 4 9 . 7 D 4 9 . 8 9 D 4 9 . 9 D 6 0 . 0 D 6 0 . 1

D 6 0 . 8 D 6 0 . 9 D 6 1 . 0 1 D 6 1 . 0 9 D 6 1 . 1 D 6 1 . 2 D 6 1 . 3 D 6 1 . 8 1 8 D 6 1 . 8 9 D 6 1 . 9 D 6 9 . 4 9 D 6 9 . 6 D 6 9 . 8 D 6 9 . 9 D 7 0 . 8 D 7 0 . 9 D 7 2 . 8 1 0 D 7 2 . 8 1 8 D 7 2 . 8 1 9 D 7 2 . 8 2 1 D 7 2 . 8 2 8 D 7 2 . 8 2 9 D 7 2 . 8 9 D 7 2 . 9 D 7 5 . 8 1 D 7 5 . 8 9 D 7 5 . 9 D 7 7 E 0 1 . 0 E 0 1 . 1 E 0 1 . 2 E 0 4 . 0 E 0 4 . 1 E 0 4 . 2 E 0 4 . 8 E 0 4 . 9 E 3 4 . 0 J 9 1 . 0 K 5 0 . 0 0 K 6 3 . 5 L 8 5 . 3 M 0 5 . 0 1 1 M 0 5 . 0 1 2 M 0 5 . 0 2 1 M 0 5 . 0 2 2 M 0 5 . 0 3 1 M 0 5 . 0 3 2 M 0 5 . 0 4 1 M 0 5 . 0 4 2 M 0 5 . 0 5 1 M 0 5 . 0 5 2 M 0 5 . 0 6 1 M 0 5 . 0 6 2 M 0 5 . 0 7 1 M 0 5 . 0 7 2 M 0 5 . 0 9 M 0 5 . 1 1 1 M 0 5 . 1 1 2

M 0 5 . 1 2 1 M 0 5 . 1 2 2 M 0 5 . 1 3 1 M 0 5 . 1 3 2 M 0 5 . 1 4 1 M 0 5 . 1 4 2 M 0 5 . 1 5 1 M 0 5 . 1 5 2 M 0 5 . 1 6 1 M 0 5 . 1 6 2 M 0 5 . 1 7 1 M 0 5 . 1 7 2 M 0 5 . 1 9 M 0 5 . 2 1 1 M 0 5 . 2 1 2 M 0 5 . 2 2 1 M 0 5 . 2 2 2 M 0 5 . 2 3 1 M 0 5 . 2 3 2 M 0 5 . 2 4 1 M 0 5 . 2 4 2 M 0 5 . 2 5 1 M 0 5 . 2 5 2 M 0 5 . 2 6 1 M 0 5 . 2 6 2 M 0 5 . 2 7 1 M 0 5 . 2 7 2 M 0 5 . 2 9 M 0 5 . 3 1 1 M 0 5 . 3 1 2 M 0 5 . 3 2 1 M 0 5 . 3 2 2 M 0 5 . 3 3 1 M 0 5 . 3 3 2 M 0 5 . 3 4 1 M 0 5 . 3 4 2 M 0 5 . 3 5 1 M 0 5 . 3 5 2 M 0 5 . 3 6 1 M 0 5 . 3 6 2 M 0 5 . 3 7 1 M 0 5 . 3 7 2 M 0 5 . 3 9 M 0 5 . 4 1 1 M 0 5 . 4 1 2 M 0 5 . 4 2 1 M 0 5 . 4 2 2 M 0 5 . 4 3 1 M 0 5 . 4 3 2 M 0 5 . 4 4 1 M 0 5 . 4 4 2 M 0 5 . 4 5 1 M 0 5 . 4 5 2 M 0 5 . 4 6 1 M 0 5 . 4 6 2 M 0 5 . 4 7 1 M 0 5 . 4 7 2 M 0 5 . 4 9

M 0 5 . 5 1 1 M 0 5 . 5 1 2 M 0 5 . 5 2 1 M 0 5 . 5 2 2 M 0 5 . 5 3 1 M 0 5 . 5 3 2 M 0 5 . 5 4 1 M 0 5 . 5 4 2 M 0 5 . 5 5 1 M 0 5 . 5 5 2 M 0 5 . 5 6 1 M 0 5 . 5 6 2 M 0 5 . 5 7 1 M 0 5 . 5 7 2 M 0 5 . 5 9 M 0 5 . 6 1 1 M 0 5 . 6 1 2 M 0 5 . 6 2 1 M 0 5 . 6 2 2 M 0 5 . 6 3 1 M 0 5 . 6 3 2 M 0 5 . 6 4 1 M 0 5 . 6 4 2 M 0 5 . 6 5 1 M 0 5 . 6 5 2 M 0 5 . 6 6 1 M 0 5 . 6 6 2 M 0 5 . 6 7 1 M 0 5 . 6 7 2 M 0 5 . 6 9 M 0 5 . 7 1 1 M 0 5 . 7 1 2 M 0 5 . 7 2 1 M 0 5 . 7 2 2 M 0 5 . 7 3 1 M 0 5 . 7 3 2 M 0 5 . 7 4 1 M 0 5 . 7 4 2 M 0 5 . 7 5 1 M 0 5 . 7 5 2 M 0 5 . 7 6 1 M 0 5 . 7 6 2 M 0 5 . 7 7 1 M 0 5 . 7 7 2 M 0 5 . 7 9 M 0 5 . 8 1 1 M 0 5 . 8 1 2 M 0 5 . 8 2 1 M 0 5 . 8 2 2 M 0 5 . 8 3 1 M 0 5 . 8 3 2 M 0 5 . 8 4 1 M 0 5 . 8 4 2 M 0 5 . 8 5 1 M 0 5 . 8 5 2 M 0 5 . 8 6 1 M 0 5 . 8 6 2 M 0 5 . 8 7 1

M 0 5 . 8 7 2 M 0 5 . 8 9 M 0 6 . 0 1 1 M 0 6 . 0 1 2 M 0 6 . 0 2 1 M 0 6 . 0 2 2 M 0 6 . 0 3 1 M 0 6 . 0 3 2 M 0 6 . 0 4 1 M 0 6 . 0 4 2 M 0 6 . 0 5 1 M 0 6 . 0 5 2 M 0 6 . 0 6 1 M 0 6 . 0 6 2 M 0 6 . 0 7 1 M 0 6 . 0 7 2 M 0 6 . 0 8 M 0 6 . 0 9 M 0 6 . 1 M 0 6 . 2 1 1 M 0 6 . 2 1 2 M 0 6 . 2 2 1 M 0 6 . 2 2 2 M 0 6 . 2 3 1 M 0 6 . 2 3 2 M 0 6 . 2 4 1 M 0 6 . 2 4 2 M 0 6 . 2 5 1 M 0 6 . 2 5 2 M 0 6 . 2 6 1 M 0 6 . 2 6 2 M 0 6 . 2 7 1 M 0 6 . 2 7 2 M 0 6 . 2 8 M 0 6 . 2 9 M 0 6 . 3 1 1 M 0 6 . 3 1 2 M 0 6 . 3 2 1 M 0 6 . 3 2 2 M 0 6 . 3 3 1 M 0 6 . 3 3 2 M 0 6 . 3 4 1 M 0 6 . 3 4 2 M 0 6 . 3 5 1 M 0 6 . 3 5 2 M 0 6 . 3 6 1 M 0 6 . 3 6 2 M 0 6 . 3 7 1 M 0 6 . 3 7 2 M 0 6 . 3 8 M 0 6 . 3 9 M 0 6 . 8 1 1 M 0 6 . 8 1 2 M 0 6 . 8 2 1 M 0 6 . 8 2 2 M 0 6 . 8 3 1 M 0 6 . 8 3 2 M 0 6 . 8 4 1

M 0 6 . 8 4 2 M 0 6 . 8 5 1 M 0 6 . 8 5 2 M 0 6 . 8 6 1 M 0 6 . 8 6 2 M 0 6 . 8 7 1 M 0 6 . 8 7 2 M 0 6 . 8 8 M 0 6 . 8 9 N 4 0 . 0 N 4 0 . 1 N 4 0 . 2 N 4 0 . 3 N 4 2 . 3 1 N 4 2 . 3 2 N 4 2 . 3 9 N 4 2 . 8 3 R 1 6 . 1 R 1 6 . 2 R 3 1 . 0 R 3 1 . 1 R 3 1 . 2 9 R 3 1 . 9 R 9 9 Z 0 0 . 0 0 Z 0 0 . 0 1 Z 0 0 . 1 1 0 Z 0 0 . 1 1 1 Z 0 0 . 1 2 1

Z 0 0 . 1 2 9 Z 0 0 . 5 Z 0 0 . 7 0 Z 0 0 . 7 1 Z 0 0 . 8 Z 0 2 . 0 Z 0 2 . 1 Z 0 2 . 2 Z 0 2 . 3 Z 0 2 . 4 Z 0 2 . 5 Z 0 2 . 6 Z 0 2 . 7 1 Z 0 2 . 7 9 Z 0 2 . 8 1 Z 0 2 . 8 2 Z 0 2 . 8 3 Z 0 2 . 8 9 Z 0 2 . 9 Z 0 4 . 6 Z 0 4 . 8 Z 0 4 . 8 1 Z 0 4 . 8 2 Z 0 4 . 8 9 Z 0 4 . 9 Z 1 1 . 0 Z 1 1 . 1 Z 1 1 . 2 Z 1 1 . 3 Z 1 1 . 4 Z 1 1 . 5 1 Z 1 1 . 5 9 Z 1 1 . 6 Z 1 1 . 7 Z 1 1 . 8 Z 1 1 . 9 Z 1 2 . 0 Z 1 2 . 1 0 Z 1 2 . 1 3 Z 1 2 . 2 Z 1 2 . 6 Z 1 2 . 7 1 Z 1 2 . 7 2 Z 1 2 . 7 3 Z 1 2 . 7 9 Z 1 2 . 8 1 Z 1 2 . 8 2 Z 1 2 . 8 3 Z 1 2 . 8 9 Z 1 2 . 9 Z 1 3 . 0 Z 1 3 . 2 1 Z 1 3 . 2 2 0 Z 1 3 . 2 2 8 Z 1 3 . 2 9 Z 1 3 . 3 Z 1 3 . 3 0 Z 1 3 . 3 1

Z 1 3 . 3 2 Z 1 3 . 3 9 Z 1 3 . 4 Z 1 3 . 4 0 Z 1 3 . 4 1 Z 1 3 . 4 2 Z 1 3 . 4 9 Z 1 3 . 5 Z 1 3 . 7 1 Z 1 3 . 7 9 Z 1 3 . 8 1 0 Z 1 3 . 8 1 1 Z 1 3 . 8 1 8 Z 1 3 . 8 2 0 Z 1 3 . 8 2 8 Z 1 3 . 8 3 Z 1 3 . 8 4 Z 1 3 . 8 5 0 Z 1 3 . 8 5 8 Z 1 3 . 8 8 Z 1 3 . 8 9 Z 1 3 . 9 Z 1 5 . 0 4 Z 1 5 . 0 9 Z 1 7 . 0 Z 3 6 . 0 Z 3 6 . 1 Z 3 6 . 2 Z 3 6 . 3 Z 3 6 . 4 Z 3 6 . 5 Z 3 6 . 8 1 Z 3 6 . 8 2 Z 3 6 . 8 3 Z 3 6 . 8 4 Z 3 6 . 8 5 Z 3 6 . 8 6 Z 3 6 . 8 7 Z 3 6 . 8 8 Z 3 6 . 8 9 Z 3 6 . 8 A Z 3 6 . 9 Z 4 0 . 0 0 Z 4 0 . 0 1 Z 4 0 . 0 2 Z 4 0 . 0 9 Z 4 0 . 8 Z 4 0 . 9 Z 4 1 . 1 Z 4 1 . 2 Z 4 1 . 3 Z 4 1 . 8 Z 4 1 . 9 Z 4 6 . 1 Z 4 8 . 2 1 Z 5 6 . 0 Z 5 6 . 2 Z 5 6 . 3

Z 5 6 . 4 Z 5 6 . 5 Z 5 6 . 6 Z 5 6 . 8 1 Z 5 6 . 8 2 Z 5 6 . 8 9 Z 5 6 . 9 Z 5 7 . 0 Z 5 7 . 1 Z 5 7 . 2 Z 5 7 . 3 1 Z 5 7 . 3 9 Z 5 7 . 4 Z 5 7 . 5 Z 5 7 . 6 Z 5 7 . 7 Z 5 7 . 8 Z 5 7 . 9 Z 5 9 . 0 Z 5 9 . 1 Z 5 9 . 2 Z 5 9 . 3 Z 5 9 . 4 Z 5 9 . 5 Z 5 9 . 6 Z 5 9 . 7 Z 5 9 . 8 Z 5 9 . 9 Z 6 0 . 2 Z 6 2 . 2 1 Z 7 1 . 0 Z 7 4 . 1 Z 7 4 . 2 Z 7 4 . 3 Z 7 4 . 8 Z 7 4 . 9 Z 7 5 . 5 Z 7 6 . 0 Z 7 6 . 1 Z 7 6 . 2 Z 7 6 . 3 Z 7 6 . 4 Z 7 6 . 8 1 Z 8 0 . 0 Z 8 0 . 1 Z 8 0 . 2 Z 8 0 . 4 9 Z 8 0 . 5 1 Z 8 0 . 5 2 Z 8 0 . 5 9 Z 8 0 . 6 Z 8 0 . 7 Z 8 0 . 8 Z 8 0 . 9 Z 8 1 . 0 Z 8 1 . 1 Z 8 1 . 2 Z 8 1 . 3

Z 8 1 . 4 Z 8 1 . 8 Z 8 2 . 0 Z 8 2 . 1 Z 8 2 . 2 Z 8 2 . 3 Z 8 2 . 4 1 Z 8 2 . 4 9 Z 8 2 . 5 Z 8 2 . 6 1 Z 8 2 . 6 2 Z 8 2 . 6 9 Z 8 2 . 7 1 Z 8 2 . 7 9 Z 8 2 . 8 Z 8 3 . 0 Z 8 3 . 1 Z 8 3 . 2 Z 8 3 . 3 Z 8 3 . 4 1 Z 8 3 . 4 9 Z 8 3 . 5 1 1 Z 8 3 . 5 1 8 Z 8 3 . 5 2 Z 8 3 . 6 Z 8 3 . 7 1 Z 8 3 . 7 9 Z 8 4 . 0 Z 8 4 . 1 Z 8 4 . 2 Z 8 4 . 3 Z 8 4 . 8 1 Z 8 4 . 8 9 Z 8 5 . 0 0 Z 8 5 . 0 3 8 Z 8 5 . 0 4 8 Z 8 5 . 4 2 Z 8 5 . 4 3 Z 8 5 . 5 1 Z 8 5 . 5 3 Z 8 5 . 5 4 Z 8 5 . 5 9 Z 8 5 . 8 2 0 Z 8 5 . 8 4 1 Z 8 6 . 0 1 0 Z 9 4 . 1 Z 9 4 . 8 4

0 0 0 1 U 0 0 0 2 M 0 0 0 2 U 0 0 0 3 M 0 0 0 3 U 0 0 0 4 M 0 0 0 5 U 0 0 0 6 M 0 0 0 6 U 0 0 0 7 M 0 0 0 7 U 0 0 0 8 U 0 0 0 9 M 0 0 0 9 U 0 0 1 0 U 0 0 1 1 M 0 0 1 1 U 0 0 1 2 M 0 0 1 2 U 0 0 1 3 M 0 0 1 3 U 0 0 1 4 U 0 0 1 6 U 0 0 1 7 U 0 0 1 8 U 0 0 1 9 U 0 0 2 1 U 0 0 2 2 U 0 0 2 3 U 0 0 2 4 U 0 0 2 5 U 0 0 2 6 U 0 0 2 7 U 0 0 2 9 U 0 0 3 0 U 0 0 3 1 U 0 0 3 2 U 0 0 3 3 U 0 0 3 4 U 0 0 3 5 U 0 0 3 6 U 0 0 3 7 U 0 0 3 8 U 0 0 3 9 U 0 0 4 0 U 0 0 4 1 U 0 0 4 2 U 0 0 4 3 U 0 0 4 4 U 0 0 4 5 U 0 0 4 6 U 0 0 4 7 U 0 0 4 8 U 0 0 4 9 U 0 0 5 0 U 0 0 5 3 U

0 0 5 5 U 0 0 5 6 U 0 0 5 7 U 0 0 5 8 U 0 0 5 9 U 0 0 6 1 U 0 0 6 2 U 0 0 6 3 U 0 0 6 7 U 0 0 6 9 U 0 0 7 0 U 0 0 7 1 U 0 0 7 2 U 0 0 7 3 U 0 0 7 4 U 0 0 7 5 U 0 0 7 6 U 0 0 7 7 U 0 0 7 8 U 0 0 7 9 U 0 0 8 0 U 0 0 8 1 U 0 0 8 3 U 0 0 8 4 U 0 0 8 5 U 0 0 8 7 U 0 0 8 8 U 0 0 8 9 U 0 0 9 0 U 0 0 9 1 U 0 0 9 2 U 0 0 9 3 U 0 0 9 4 U 0 0 9 5 U 0 1 0 1 U 0 1 0 2 U 0 1 0 3 U 0 1 0 4 U 0 1 0 5 U 0 1 0 8 U 0 1 1 1 U 0 1 1 3 U 0 1 1 4 U 0 1 1 8 U 0 1 2 0 U 0 1 2 9 U 0 1 3 0 U 0 1 3 1 U 0 1 3 2 U 0 1 3 3 U 0 1 3 4 U 0 1 3 5 U 0 1 3 6 U 0 1 3 7 U 0 1 3 8 U 0 1 5 3 U 0 1 5 4 U 0 1 5 5 U

0 1 5 6 U 0 1 5 7 U 0 1 5 8 U 0 1 5 9 U 0 1 6 0 U 0 1 6 1 U 0 1 6 2 U 8 1 1 0 5 8 1 1 0 6 8 1 1 0 7 8 1 1 0 8 8 1 1 0 9 8 1 1 1 0 8 1 1 1 1 8 1 1 1 2 8 1 1 2 0 8 1 1 2 1 8 1 1 6 1 8 1 1 6 2 8 1 1 6 3 8 1 1 6 4 8 1 1 6 5 8 1 1 6 6 8 1 1 6 7 8 1 1 7 0 8 1 1 7 1 8 1 1 7 2 8 1 1 7 3 8 1 1 7 4 8 1 1 7 5 8 1 1 7 6 8 1 1 7 7 8 1 1 7 8 8 1 1 7 9 8 1 1 8 0 8 1 1 8 1 8 1 1 8 2 8 1 1 8 3 8 1 1 8 4 8 1 1 8 5 8 1 1 8 6 8 1 1 8 7 8 1 1 8 8 8 1 1 8 9 8 1 1 9 0 8 1 2 0 0 8 1 2 0 1 8 1 2 0 2 8 1 2 0 3 8 1 2 0 4 8 1 2 0 5 8 1 2 0 6 8 1 2 0 7 8 1 2 0 8 8 1 2 0 9 8 1 2 1 0 8 1 2 1 1 8 1 2 1 2

8 1 2 1 3 8 1 2 1 4 8 1 2 1 5 8 1 2 1 6 8 1 2 1 7 8 1 2 1 8 8 1 2 1 9 8 1 2 2 0 8 1 2 2 1 8 1 2 2 2 8 1 2 2 3 8 1 2 2 4 8 1 2 2 5 8 1 2 2 6 8 1 2 2 7 8 1 2 2 8 8 1 2 2 9 8 1 2 3 0 8 1 2 3 1 8 1 2 3 2 8 1 2 3 3 8 1 2 3 4 8 1 2 3 5 8 1 2 3 6 8 1 2 3 7 8 1 2 3 8 8 1 2 3 9 8 1 2 4 0 8 1 2 4 1 8 1 2 4 2 8 1 2 4 3 8 1 2 4 4 8 1 2 4 5 8 1 2 4 6 8 1 2 4 7 8 1 2 4 8 8 1 2 4 9 8 1 2 5 0 8 1 2 5 1 8 1 2 5 2 8 1 2 5 3 8 1 2 5 4 8 1 2 5 5 8 1 2 5 6 8 1 2 5 7 8 1 2 5 8 8 1 2 5 9 8 1 2 6 0 8 1 2 6 1 8 1 2 6 2 8 1 2 6 3 8 1 2 6 4 8 1 2 6 5 8 1 2 6 6 8 1 2 6 7 8 1 2 6 8 8 1 2 6 9 8 1 2 7 0

8 1 2 7 1 8 1 2 7 2 8 1 2 7 3 8 1 2 7 4 8 1 2 7 5 8 1 2 7 6 8 1 2 7 7 8 1 2 8 3 8 1 2 8 4 8 1 2 8 5 8 1 2 8 6 8 1 2 8 7 8 1 2 8 8 8 1 2 8 9 8 1 2 9 0 8 1 2 9 1 8 1 2 9 2 8 1 2 9 3 8 1 2 9 4 8 1 2 9 5 8 1 2 9 6 8 1 2 9 7 8 1 2 9 8 8 1 2 9 9 8 1 3 0 0 8 1 3 0 1 8 1 3 0 2 8 1 3 0 3 8 1 3 0 4 8 1 3 0 5 8 1 3 0 6 8 1 3 0 7 8 1 3 0 8 8 1 3 0 9 8 1 3 1 0 8 1 3 1 1 8 1 3 1 2 8 1 3 1 3 8 1 3 1 4 8 1 3 1 5 8 1 3 1 6 8 1 3 1 7 8 1 3 1 8 8 1 3 1 9 8 1 3 2 0 8 1 3 2 1 8 1 3 2 2 8 1 3 2 3 8 1 3 2 4 8 1 3 2 5 8 1 3 2 6 8 1 3 2 7 8 1 3 2 8 8 1 3 2 9 8 1 3 3 0 8 1 3 3 1 8 1 3 3 2 8 1 3 3 3

8 1 3 3 4 8 1 3 3 5 8 1 3 3 6 8 1 3 3 7 8 1 3 4 0 8 1 3 4 1 8 1 3 4 2 8 1 3 4 3 8 1 3 4 4 8 1 3 4 5 8 1 3 4 6 8 1 3 5 0 8 1 3 5 5 8 1 3 6 1 8 1 3 6 2 8 1 3 6 3 8 1 3 6 4 8 1 4 1 0 8 1 4 1 1 8 1 4 1 2 8 1 4 1 3 8 1 4 1 4 8 1 4 1 5 8 1 4 1 6 8 1 4 1 7 8 1 4 2 0 8 1 4 2 2 8 1 4 2 5 8 1 4 2 6 8 1 4 2 7 8 1 4 3 0 8 1 4 3 1 8 1 4 3 2 8 1 4 3 3 8 1 4 3 4 8 1 4 3 5 8 1 4 3 6 8 1 4 3 7 8 1 4 3 8 8 1 4 4 0 8 1 4 4 2 8 1 4 4 3 8 1 4 4 5 8 1 4 4 8 8 1 4 5 0 8 1 4 5 5 8 1 4 6 0 8 1 4 6 5 8 1 4 7 0 8 1 4 7 1 8 1 4 7 9 8 1 4 9 0 8 1 4 9 3 8 1 5 0 0 8 1 5 0 3 8 1 5 0 4 8 1 5 0 6 8 1 5 1 8

8 1 5 1 9 8 1 5 2 0 8 1 5 2 1 8 1 5 2 2 8 1 5 2 5 8 1 5 3 5 8 1 5 3 6 8 1 5 3 8 8 1 5 3 9 8 1 5 4 0 8 1 5 4 1 8 1 5 4 2 8 1 5 4 5 8 1 5 5 1 8 1 5 5 2 8 1 5 9 5 8 1 5 9 9 8 4 9 9 9 8 5 9 9 9 8 6 1 5 2 8 6 1 5 3 8 6 2 9 4 8 6 3 1 6 8 6 3 8 6 8 6 8 4 9 8 8 1 2 0 8 8 1 2 1 8 8 1 9 9 8 8 3 4 1 8 8 3 4 2 8 8 3 6 3 8 8 3 6 5 8 8 3 6 7 8 8 3 6 8 8 8 3 9 9 8 9 2 4 0 8 9 3 9 8 G 0 4 5 2 S 0 2 6 5 S 3 8 0 0 S 3 8 4 1 S 3 8 4 2 S 3 8 4 5 S 3 8 4 6 S 3 8 4 9 S 3 8 5 0 S 3 8 5 2 S 3 8 5 3 S 3 8 6 1 S 3 8 7 0

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Molecular Pathology/Molecular Diagnostics/Genetic Testing · 2020-01-04 · Molecular Pathology/Molecular Diagnostics/Genetic Testing Page 2 of 55 UnitedHealthcare Medicare Advantage