LCD : HCG - Human chorionic gonadotropin-Tumor Antigen by Immunoassay, Qualitative (L1565)

LCD for HCG - Human chorionic gonadotropin-Tumor Antigen by Immunoassay, Qualitative (L1565)

Contractor Information

Contractor Name

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)

Contractor Number

00390

Contractor Type

LCD Information

LCD ID Number

L1565

LCD Title

HCG - Human chorionic gonadotropin-Tumor Antigen by Immunoassay, Qualitative

Contractor's Determination Number

1565

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 of 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

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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

HCG - Human chorionic gonadotropin-Tumor Antigen by Immunoassay, Qualitative.

Indications:

HCG is useful for monitoring and diagnosis of germ cell neoplasms of the following:

ovary
testis, mediastinum
retroperitoneum
central nervous system

HCG may be useful for diagnosis of pregnancy and pregnancy-associated conditions.

Limitations:

HCG should not be used more than once per month for diagnostic purposes.
Qualitative HCG assays are not appropriate for medically managing patients with known or suspected germ cell neoplasms.

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

84703

GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE

ICD-9 Codes that Support Medical Necessity

158.0	MALIGNANT NEOPLASM OF RETROPERITONEUM
158.8	MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM
164.2	MALIGNANT NEOPLASM OF ANTERIOR MEDIASTINUM
164.3	MALIGNANT NEOPLASM OF POSTERIOR MEDIASTINUM
164.8	MALIGNANT NEOPLASM OF OTHER PARTS OF MEDIASTINUM
164.9	MALIGNANT NEOPLASM OF MEDIASTINUM PART UNSPECIFIED
181	MALIGNANT NEOPLASM OF PLACENTA
182.0 - 182.8	MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT ISTHMUS - MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BODY OF UTERUS
183.0	MALIGNANT NEOPLASM OF OVARY
183.2	MALIGNANT NEOPLASM OF FALLOPIAN TUBE
183.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA
186.0	MALIGNANT NEOPLASM OF UNDESCENDED TESTIS
186.9	MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED TESTIS
194.4	MALIGNANT NEOPLASM OF PINEAL GLAND
197.1	SECONDARY MALIGNANT NEOPLASM OF MEDIASTINUM
197.6	SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM
198.6	SECONDARY MALIGNANT NEOPLASM OF OVARY
198.82	SECONDARY MALIGNANT NEOPLASM OF GENITAL ORGANS
236.1	NEOPLASM OF UNCERTAIN BEHAVIOR OF PLACENTA
623.8	OTHER SPECIFIED NONINFLAMMATORY DISORDERS OF VAGINA
625.9	UNSPECIFIED SYMPTOM ASSOCIATED WITH FEMALE GENITAL ORGANS
630	HYDATIDIFORM MOLE
631	OTHER ABNORMAL PRODUCT OF CONCEPTION
632	MISSED ABORTION
633.00 - 633.81	ABDOMINAL PREGNANCY WITHOUT INTRAUTERINE PREGNANCY - OTHER ECTOPIC PREGNANCY WITH INTRAUTERINE PREGNANCY
634.00 - 634.92	SPONTANEOUS ABORTION UNSPECIFIED COMPLICATED BY GENITAL TRACT AND PELVIC INFECTION - SPONTANEOUS ABORTION COMPLETE WITHOUT COMPLICATION
640.00 - 640.03	THREATENED ABORTION UNSPECIFIED AS TO EPISODE OF CARE - THREATENED ABORTION ANTEPARTUM
642.30 - 642.34	TRANSIENT HYPERTENSION OF PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE - POSTPARTUM TRANSIENT HYPERTENSION
642.40 - 642.74	MILD OR UNSPECIFIED PRE-ECLAMPSIA UNSPECIFIED AS TO EPISODE OF CARE - PRE-ECLAMPSIA OR ECLAMPSIA SUPERIMPOSED ON PRE-EXISTING HYPERTENSION POSTPARTUM
642.90 - 642.94	UNSPECIFIED HYPERTENSION COMPLICATING PREGNANCY CHILDBIRTH OR THE PUERPERIUM UNSPECIFIED AS TO EPISODE OF CARE - UNSPECIFIED POSTPARTUM HYPERTENSION
V10.09	PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER SITES IN GASTROINTESTINAL TRACT
V10.29	PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER RESPIRATORY AND INTRATHORACIC ORGANS
V10.43	PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OVARY
V10.47	PERSONAL HISTORY OF MALIGNANT NEOPLASM OF TESTIS
V22.0 - V23.9	SUPERVISION OF NORMAL FIRST PREGNANCY - SUPERVISION OF UNSPECIFIED HIGH-RISK PREGNANCY
V71.1	OBSERVATION FOR SUSPECTED MALIGNANT NEOPLASM
V72.40*	PREGNANCY EXAMINATION OR TEST, PREGNANCY UNCONFIRMED
V72.41*	PREGNANCY EXAMINATION OR TEST, NEGATIVE RESULT
*latest code update

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.

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

O'Callaghan A. Mead GM. Testicular carcinoma. [Review] [23 Refs] Postgraduate Medical Journal. 73(862):4816, 1997 Aug.

Sawamura Y. Current diagnosis and treatment of central nervous system germ cell tumours. [Review] [47 Refs] Current Opinion in Neurology. 9(6):41923, 1996 Dec.

Wilkins M. Horwich A. Diagnosis and treatment of urological malignancy: The testes. [Review] [23 Refs] British Journal of Hospital Medicine. 55(4): 199203, 1996. Feb 21, Mar 5.

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

073-99i

Revision History Explanation

10/01/2004 Annual ICD-9 Code Update: Relace V72.4 with V72.40 and V72.41. in field ICD-9 Codes that Support Medical Necessity.

01/17/2003 Revised to include only Qualitative (84703) and deleted Quantitative (84702) which now has a National Coverage Decision (NCD). Added 12x to Type of Bill Code.

07/24/2002 Formatted

01/18/2002 Updated codes (Negotiated Rulemaking: Coverage and Administrative Policies for Clinical Diagnostic Laboratory Services; Final Rule: Nov 2001)

03/23/2001 added ICD-9 codes

02/27/2001 ICD-9 & CPT codes checked with 2001 code books

08/30/2000 codes added for Carrier consistency and clarification of reasons for denial

09/04/2005 - This policy was updated by the ICD-9 2005-2006 Annual Update.

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

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

10/05/2007 - Frequently Asked Question restored to Appendices.