LCD Reference Article Response To Comments Article

Response to Comments: MolDX: BRCA1 and BRCA2 Genetic Testing

A54814

Expand All | Collapse All
Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website.
Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A54814
Original ICD-9 Article ID
Not Applicable
Article Title
Response to Comments: MolDX: BRCA1 and BRCA2 Genetic Testing
Article Type
Response to Comments
Original Effective Date
02/15/2016
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement Date
N/A

CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association.

Current Dental Terminology © 2025 American Dental Association. All rights reserved.

Copyright © 2025, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at ub04@aha.org or 312‐422‐3366.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

N/A

Article Guidance

Article Text
The comment period began on 10/13/15 and ended on 11/27/2015. Comments were received from the provider community. The notice period begins on 12/31/2015 and ends 2/14/2016. The LCD becomes final on 2/15/2016

Response To Comments

Number Comment Response
1 Add ICD-10 Z85.3 – Personal history of malignant neoplasm of breast Z85.3 added.
2 Update HBOC testing criteria according to NCCN v.2.2015. Policy updated with NCCN v.2.2015 testing criteria.
3 Clarify indicators for individuals who have been adopted BRCA testing should be available to individuals who are adopted, know little about their family health history, come from small families, and in the case of sex-specific conditions, have few female/male relatives at risk of developing a particular condition if they have a personal history of one of the BRCA-related cancer and have received genetic counseling.
4 Adjust pricing to enable broader access to testing Medicare is a defined benefit program. There is no co-pay for diagnostic testing. Consequently, pricing does not affect access to testing.
5 Encourage use of multi-gene panels when there is no difference in cost Multi-gene panels provide an alternative testing approach at less cost than other gene testing methodologies and should be left to the discretion of the ordering physician. However, there are many challenges that affect multi-gene panels including the absence of cross-validation between different testing platforms and different labs; lack of AV/CV testing standards; absence of publication of AV/CV performance by individual laboratories so the public as assess quality of testing; limited multi-gene proficiency testing; absence of standardized gene panels for a given disease; large number of VUS that leave clinicians and patients in a diagnostic and clinical quandary; absence of clear guidelines regarding degree of cancer risk associated with some of the genes, particularly moderate-penetrance genes; Medicare reimbursement is limited to genes with proven clinical utility, etc. NCCN recognizes that multi-gene testing is a new field, and acknowledges there is a lack of evidence regarding proper procedures and risk management especially for moderate-penetrance genes and when a VUS is found. For this reason, NCCN recommends that multi-gene testing be offered in the context of professional genetic expertise, with pre- and post-test counseling.
6 Provide coverage for genetic counseling services, including those proved by cancer genetics professional employed by commercial laboratories. At the current time, genetic counselors are not recognized Medicare providers. Congress determines Medicare providers.
7 Commenter supports “once in a lifetime requirement”. Germline testing does not change with time, thus once in a lifetime.
N/A

Coding Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
N/A
Related National Coverage Documents
NCDs
N/A
SAD Process URL 1
N/A
SAD Process URL 2
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
12/28/2015 02/15/2016 - N/A Currently in Effect You are here

Keywords

N/A