LCD : Bladder Tumor Antigen (L1303)

LCD for Bladder Tumor Antigen (L1303)

Contractor Information

Contractor Name

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)

Contractor Number

00390

Contractor Type

LCD Information

LCD ID Number

L1303

LCD Title

Bladder Tumor Antigen

Contractor's Determination Number

1303

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section excludes coverage for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Primary Geographic Jurisdiction

New Jersey
Tennessee

Secondary Geographic Jurisdiction

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming

Oversight Region

Region IV

Original Determination Effective Date

For services performed on or after 07/01/1997

Original Determination Ending Date

Revision Effective Date

For services performed on or after 12/08/2005

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

Bladder tumor antigen (BTA) is a latex agglutination assay for the qualitative detection of bladder tumor antigen in the urine. The antigen is composed of basement membrane complexes that have been isolated and characterized from the urine of patients with bladder cancer.

Indications:

The BTA test may be used as a method of surveillance for patients with previously diagnosed bladder cancer

Limitations:
The physician must clearly document in the patient’s record that the patient has a history of bladder cancer.

The BTA test is not covered for screening purposes.

Coverage Topic

Lab Services

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12x	Hospital-inpatient or home health visits (Part B only)
13x	Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
14x	Non-Patient Laboratory Specimens

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

030X	Laboratory-general classification
031X	Laboratory pathological-general classification

CPT/HCPCS Codes

86294

IMMUNOASSAY FOR TUMOR ANTIGEN, QUALITATIVE OR SEMIQUANTITATIVE (EG, BLADDER TUMOR ANTIGEN)

ICD-9 Codes that Support Medical Necessity

188.0 - 188.9	MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER - MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED
198.1	SECONDARY MALIGNANT NEOPLASM OF OTHER URINARY ORGANS
233.7	CARCINOMA IN SITU OF BLADDER
239.4	NEOPLASM OF UNSPECIFIED NATURE OF BLADDER
V10.51	PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BLADDER

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentation Requirements

Documents supporting medical necessity of this test, such as ICD-9 diagnosis code(s), must be submitted with each claim. Claims submitted without such evidence will be denied as being not medically necessary.

The following documents must be made available to Medicare upon request:

All medical records for services billed
Results of laboratory test
Itemization of charges

Appendices

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:
Frequently Asked Questions

Utilization Guidelines

Sources of Information and Basis for Decision

Pathology and Urology Consults

Carrier Medical Directors Clinical Laboratory Workgroup

Other Medical Part B Carriers' Local Medical Review Policies

Medical Tests of Diagnosis

Advisory Committee Meeting Notes

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives.

Start Date of Comment Period

11/27/1996

End Date of Comment Period

Start Date of Notice Period

12/27/1996

Revision History Number

068-99h

Revision History Explanation

01/09/2003 Added 12X to Type of Bill Code

07/24/2002 Formatted

01/25/2002 Updated CPT [2002 Code Book]

02/26/2001 checked ICD-9 & CPT codes with 2001 code books.

08/30/2000 updated for clarification of coverage issues.

This LCD was converted from an LMRP on 12/7/2005

7/2/2006 - The description for Bill code 14 was changed

10/02/2007 - Frequently Asked Questions restored to Appendices.